Professional Documents
Culture Documents
November 2015
Guideline Development Group
The National Clinical Guideline on Management of an Acute Asthma Attack in Adults was
developed by a sub-group of the National Clinical Programme for Asthma (NCPA). The Guideline
Development Group was chaired by Professor Pat Manning.
The National Clinical Programmes including the National Clinical Programme for Asthma
(NPCA) were set up through the HSE’s Clinical Strategy and Programmes Division with the aim
of delivering better care and outcomes through the best use of resources, delivered through
standardised care pathways and models of care for the patient journey throughout the national
health system. The Programmes are focused on transforming the way care is delivered in Ireland,
with the overarching aim of improving the quality and safety of patient care. The National
Clinical Programmes have a direct impact on the patient experience and are improving care in
a number of ways through defining the patient journey and this includes the development and
dissemination of clinical evidenced-based guidelines to standardise and improve treatment.
The development and dissemination of this Guideline on the Management of an Acute Asthma
Attack in Adults is in line with this policy. This guideline provides recommendations based on
current evidence for best practice in the management of an asthma attack in adults including
pregnant women.
Disclaimer
This guideline is not intended to be construed or to serve as a standard of care. Standards of
care are determined on the basis of all clinical data available for an individual case and are
subject to change as scientific knowledge and technology advance and patterns of care
evolve. Adherence to guideline recommendations will not ensure a successful outcome in
every case, nor should they be construed as including all proper methods of care or excluding
other acceptable methods of care aimed at the same results. The ultimate judgement must be
made by the appropriate healthcare professional(s) responsible for clinical decisions regarding
a particular clinical procedure or treatment plan. This judgement should only be arrived at
following discussion of the options with the patient, covering the diagnostic and treatment
choices available. It is advised, however, that significant departures from the national guideline
should be fully documented in the patient’s case notes at the time the relevant decision is taken.
National Clinical Effectiveness Committee (NCEC)
The National Clinical Effectiveness Committee (NCEC) was established as part of the Patient
Safety First Initiative. The NCEC is a partnership between key stakeholders in patient safety.
NCEC’s mission is to provide a framework for national endorsement of clinical guidelines and
audit to optimise patient and service user care. The NCEC has a remit to establish and implement
processes for the prioritisation and quality assurance of clinical guidelines and clinical audit so
as to recommend them to the Minister for Health to become part of a suite of National Clinical
Guidelines and National Clinical Audit.
The aim of the suite of National Clinical Guidelines is to provide guidance and standards for
improving the quality, safety and cost-effectiveness of healthcare in Ireland. The implementation
of these National Clinical Guidelines will support the provision of evidence-based and consistent
care across Irish healthcare services.
Information on the NCEC and endorsed National Clinical Guidelines is available at:
www.health.gov.ie/patient-safety/ncec
Acknowledgements
I am grateful to all who contributed to the development of this National Clinical Guideline and
in particular it would not have been possible without the enormous contribution of the members
of the National Clinical Programme for Asthma’s Guideline Development Group (GDG) the
Working Group (WG) and Clinical Advisory Group (CAG) and the reviewers (a full list is available
in Appendix 1). In addition, I would also like to acknowledge the invaluable input and assistance
in the process of completing the guideline of the following; Ms Michelle O’Neill, Senior Health
Economist, Health Technology Assessment Directorate, Health Information and Quality Authority;
Prof Stephen Lane, Chair (Clinical Advisory Committee-NCPA); Dr. Ina Kelly, Specialist in Public
Health Medicine (NCPA); the Chair, Prof Hiliary Humphrys and committee of National Clinical
Effectiveness Committee; Dr Kathleen Mac Lellan, Director of Clinical Effectiveness, and Dr Sarah
Condell and Rosarie Lynch, CMO Office, Department of Health; colleagues in the Health Service
Executive (HSE); Mr. Gethin White, Clinical Librarian, library services; National Directors, Clinical
Strategy and Programmes Division; Dr. Barry White and Dr. Aine Carroll, Prof Tim McDonald,
National Lead COPD; Valerie Twomey, Carmel Cullen, Maeve Raeside and Linda Kearns; the
CEO of Irish Thoracic Society Suzanne McCormack, and past and current presidents of the
Society, Dr Terry O’Connor, Dr. Ed McKone and Prof Anthony O‘Regan; and for support from the
Royal College of Physician in Ireland, it’s past and current President Prof John Crowe and Prof
Frank Murray and the CEO Leo Kearns; the CEO Mr Kieran Ryan and members of the Quailty
in Practice Committee of the Irish College of General Practitioners are also acknowledged. I
would like to thank all of these collegaues for sharing their time and expertise.
I would also like to express our thanks to the following; Dr Veronica Lambert and her team
at Dublin City University for their work on the guideline appraisal; Dr Roberta James, SIGN
Programme Lead and her colleague Karen King and the Scottish Intercollegiate Guidelines
Network (SIGN), Edinburgh, Scotland for use of the sections of the BTS SIGN Asthma Guidelines
included in this document; and in addition, I would also like to thank Suzanne Hurd and Board of
GINA (Global Initiative on Asthma) for access to use of sections of GINA guidelines on asthma.
_______________________________________
Section 1: Background 7
1.1 Need for a National Clinical Guideline 7
1.2 Clinical and financial impact of acute asthma 7
1.2.1 Budget impact of the proposed guidelines 7
1.2.2 The implications for service development in guideline implementation 8
1.3 Overview of epidemiology of asthma 9
1.3.1 Current levels of asthma in Ireland 9
1.3.2 Asthma deaths 9
1.4 Aim of National Clinical Guideline 10
1.5 Scope of National Clinical Guideline, target population and target audience 10
1.6 Governance 11
1.6.1 Conflict of interest statement 11
1.6.2 Sources of funding 12
1.7 methodology and literature review 12
1.7.1 Background 12
1.7.2 Objectives 12
1.7.3 Method 13
1.7.4 Strand 1: Systematically searching, retrieving and screening
clinical guidelines 13
1.7.5 Strand 2: Assessment of guideline quality 18
1.7.6 Strand 3: Analysis of guideline recommendations 20
1.7.7 Concluding summary 22
1.8 Grading of recommendations 23
1.9 External review 24
1.10 Procedure for update of National Clinical Guideline 24
1.11 Implementation of National Clinical Guideline 24
1.11.1 Facilitation of implementation 25
1.11.2 Potential barriers to implementation 25
1.12 Tools to assist the implementation of the National Clinical Guideline 25
1.13 Roles and responsibilities 25
1.13.1 Local hospital services 25
1.13.2 Primary care services 26
1.14 Audit criteria 27
1.15 Unlicensed medicines 27
Appendix 2
Summary of tools to assist in implementation of National Clinical Guideline 53
Appendix 2.1 Emergency treatment protocols for management of acute adult
asthma 54
Appendix 2.2 Emergency treatment care bundles for management of acute
adult asthma 56
Appendix 2.3 Discharge letter, fax, email template for management of acute
adult asthma 59
Appendix 2.4 Audit form for emergency asthma care 60
Appendix 2.5 Asthma management plan 61
Appendix 2.6 Peak flow measurements 63
Appendix 2.7 Medications in acute asthma 64
Appendix 3
Search sources and outputs 65
Appendix 3.1 Guideline clearing houses and organisations which develop
guidelines and/or support evidence based practice; search
sources and outputs 65
Appendix 3.2. International asthma, thoracic and lung associations. 68
Appendix 3.3 Grey literature databases 75
Appendix 3.4 Electronic databases 76
Appendix 3.5 Internet search engines 78
Appendix 4
Characteristics of retrieved guidelines 80
Appendix 5
Sample – AGREE II Instrument 84
Appendix 6
Protocol for guideline appraisal training phase 85
Appendix 7
MY AGREE PLUS 91
Appendix 8
Quality appraisal visual graphs 92
Appendix 9
Revisions to quality appraisal visual graphs 100
Appendix 10
Group consensus appraisal scores 109
Appendix 11
Description of grades of recommendations for each guideline 113
Appendix 12
Data extraction recommendation matrix 115
Appendix13
Tool 13: Evaluation sheet – search and selection of evidence 132
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Appendix 14
Tool 14: Evaluation sheet – scientific validity of guidelines
(Consistency between evidence, its interpretation and recommendations) 134
Appendix 15
Tool 15: Evaluation sheet – acceptability/applicability 136
Appendix 16
Glossary of abbreviations 137
Appendix 17
Budget impact assessment 139
Appendix 17.1 Economic impact report 139
Appendix 17.2 Budget-cost implications for implementation of acute adult
guidelines 147
Appendix 17.3 Economic search methodology 155
Appendix 18
References 158
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6 (aged 16 years and older)
List of tables
Table 1 Clinical Questions 11
Table 2 Inclusion and Exclusion Criteria 14
Table 3 Quality Score for each six AGREE II domains for both BTS/SIGN and GINA 20
Table 4 Roles and responsibilities of stakeholders in relation to the National
Clinical Guideline 26
Table 5 Levels of Severity for Adults 36
Table 6 Cost of attendance for training HSE associated staff 151
Table 7 Cost of attendance at training for other staff 152
Table 8 Estimated costs and possible savings with Implementation of Acute
Asthma Attack in Adults Guideline 156
Table 9 Search Methodology 158
List of figures
Figure 1 Asthma Epidemiology – based on 2011 data 9
Figure 2 Flowchart of search outputs and screening 17
Figure 3 Group consensus appraisal scores for the BTS/SIGN Guideline 19
Figure 4 Group consensus appraisal scores for the GINA Guideline 19
Figure 5 Rating of overall quality of the guideline 20
Figure 6 Flow Diagram of Retrieved Studies 159
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1 Background
The National Clinical Programme for Asthma (NCPA) was set up to design and standardise the
delivery of high quality asthma care to all who need it. The NCPA also focuses on improving
asthma control in the community, reducing acute asthma attendances at emergency
departments, in-patient admissions and needless deaths from asthma. A specific priority solution
to help manage patients with acute asthma attacks has been the development of this national
evidence based guideline by the NCPA.
Patients with an acute attack of asthma are at increased risk of death and readmission for
asthma if not managed appropriately (8). Patients who attend GPOOH, ED and those who are
admitted to hospital for acute asthma should be followed up by attending their GP within 2
working days of discharge for ongoing asthma management. International best practice (8)
recommends that all patients admitted to hospital should be followed up on discharge from
hospital in a medical specialist clinic for 1 year (in conjunction with their GP) until stable.
The cost impact analysis focuses on two costing areas. This is detailed in Appendix 17.
Staff training:
The main costs for guideline implementation are the costs associated with structured training
for clinical staff in hospital and GPOOH settings on acute asthma guideline managed care. It is
critical that medical staff involved with acute asthma patients have the knowledge and training
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8 (aged 16 years and older)
to manage these patients appropriately. It is estimated that the overall cost of training relevant
HSE staff would be €193,104, but these costs are mostly opportunity costs.
In relation to the above, it is estimated that there are possible annual savings of €179,978 from
reducing the use of nebulisers in the ED. Additionally, better management by specialist/asthma
nurse led clinics following discharge, leading to non-attendances at ED and GPOOH and
reduced admissions by 20%, could result in estimated annual savings of €1,380,000.
Acute Asthma Attack in Adults guideline, and to ensure that records and audit processes
and outcomes are identified and stored.
• Implementation of bundles of care for acute asthma care to encourage adherence to best
practice guidelines is recommended locally.
53
deaths
99 discharges
from ICU
5,396 inpatients
discharges
19,370 attendees in ED
Confidential enquiries into asthma deaths or near fatal asthma attacks from the UK and Ireland
have identified a number of factors which contribute to an asthma death. Most deaths from
asthma occur before admission to hospital, and usually occur in patients who have chronic
asthma, who are on inadequate inhaled corticosteroid therapy with increased reliance on
inhaled ß2-agonists (10). There is generally poor perception by the patient or physician caring for
the patient of the overall severity of the asthma attack. In addition, inadequate management
in the acute event including using sedation in some cases are also factors linked to asthma
deaths. Deaths from asthma, while uncommon, are generally preventable and occur usually
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
10 (aged 16 years and older)
in association with an acute attack. Although most of these patients have chronically severe
asthma, in a minority the fatal attack has occurred suddenly in a patient with mild or moderately
severe background disease. Most asthma deaths occur before admission to hospital.
Many deaths occur due to patients receiving inadequate treatment with inhaled steroids or
steroid tablets and/or inadequate objective monitoring of their asthma, where follow up was
inadequate in some and others should have been referred earlier for specialist advice (10).
The expected benefits resulting from the implementation of this guideline include:
• A reduction in asthma related deaths in adults
• Improved patient experience, safety and quality of care
• Raised levels of awareness among healthcare professionals on how to manage acute
asthma attacks in adults, including pregnant women
• Improved efficiency in the admission, care, discharge and follow-up of adults experiencing
an acute asthma attack
1.5 Scope of National Clinical Guideline, target population and target audience
These guidelines are for the management of acute adult asthma attack in all care settings
including primary and secondary care and specialist centres. The guideline considers all adult
patients (>16 years) with a diagnosis of asthma.
This guideline does not cover patients whose primary respiratory diagnosis is not asthma, for
example those with chronic obstructive pulmonary disease (COPD) or cystic fibrosis (CF),
although these patients may also have asthma and the principals outlined in these guidelines
may also apply to the management of their asthma component symptoms.
The scope of the recommendations set out in this document does not extend to children or
youth populations, or difficult/severe but stable asthma. Nor do the recommendations relate
to specific settings, such as primary care, and/or populations, such as pregnant women, unless
the recommendations refer to the management of an acute asthma attack in such settings/
populations.
There are separate Acute Paediatric Asthma Guidelines which have been developed by the
National Clinical Programme for Asthma.
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The recommendations set out in this National Clinical Guideline seek to address the following
clinical questions:
1.6 Governance
Governance of the guideline development process was provided by a multidisciplinary
Guideline Development Group (GDG) which was chaired by the Clinical Lead for the National
Clinical Programme for Asthma.
The GDG was responsible for the development and delivery of this National Clinical Guideline
and included representatives from relevant medical groups with expertise in the diagnosis,
treatment and care of patients with asthma.
Consultation, review and input to the guideline was sought from the Royal College of Physicians
of Ireland Clinical Advisory Group (for the NCPA) nominated by the Irish Thoracic Society, other
National Clinical Programmes and patient organisations.
The Clinical Advisory Group for the NCPA also had an oversight role.
The evidence base for this guideline is built on existing international guidelines which have been
adapted to reflect care in an Irish healthcare setting. The main evidence utilised in this guideline
is that from the Scottish Intercollegiate Guideline Network/British Thoracic Society – British
Guideline on the management of asthma, 2014 and the Global Initiative for Asthma (GINA),
updated 2015.
Permissions were sought and kindly granted from the Scottish Intercollegiate Guidelines Network
(SIGN) and Global Initiative for Asthma (GINA) for use of their guidelines in the development of
these guidelines.
the GINA Board (at the American Thoracic Society and European Respiratory Society Annual
Conferences) to share information about upcoming changes to recommendations on asthma
management, also issues of education, prevention and strategies for local dissemination of the
GINA management programme. Prof. Manning has also been involved in the implementation
of the GINA asthma management guideline in conjunction with the Irish College of General
Practitioners and the Asthma Society of Ireland, which is regularly updated.
1.7.1 Background
The goal of the review was to support the decision to develop a National Clinical Guideline
(NCG) for the Management of an Acute Asthma Attack in Adults. This NCG was to support the
Model of Care for the HSE National Clinical Programme for Asthma in Ireland, and be quality
assured by the National Clinical Effectiveness Committee (NCEC). The aim of Dr Lambert and
her team was to deliver a systematic review of clinical guidelines used in primary and secondary
care contexts. This includes general practice, paramedic services, emergency departments
and acute adult hospital contexts, for the assessment and management of the acute adult
asthma patient to improve clinical outcomes (including reduction of morbidity and mortality)
and quality of life for adults living with asthma in Ireland.
1.7.2 Objectives
The purpose of the review was to complete a systematic search for and review of guidelines
to support the adaptation of recommendations for the Irish National Clinical Guideline for the
Management of an Acute Asthma Attack in Adults.
These objectives were confirmed with the HSE Asthma Guideline Development Group (GDG)
and DoH Clinical Effectiveness Unit (CEU) through the nominated contact points prior to the
commencement of the review.
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1.7.3 Method
The methodology for this review followed the ADAPTE process as outlined in the Guideline
Adaptation Resource Toolkit (The ADAPTE Collaboration 2009) (11) and the National Clinical
Effectiveness Committee (NCEC) Guideline Development Manual of 2013 (13) with regard to
considering clinical guideline evidence for the review; search methods; guideline selection
and assessment and decisions around adaptation of guideline recommendations. Assessment
of guideline quality was guided by the AGREE II (Appraisal of Guidelines for Research and
Evaluation) Instrument (Brouwers et al. 2010) (12).
The work plan for this systematic guideline review was structured around 3 work strands;
For the S (i.e. study design) of the PICOS clinical practice guideline (CPG) was specified.
The following inclusion and exclusion criteria were used to assist in the search and retrieval of
guidelines (Table 2).
To minimise bias in the review process, the PICOs and inclusion/exclusion criteria were finalised a
priori and agreed with the Steering Committee prior to the commencement of the review.
Search methods for identifying clinical practice guidelines for the review
Drawing on step 8 and the search sources mapped in tool 2 of the ADAPTE process a variety of
sources to retrieve clinical practice guidelines for the management of acute asthma in adults
were searched, including; guideline clearinghouses; websites of organisations which specifically
develop guidelines and/or support evidence based practice; any relevant specialty societies
(i.e. asthmatic, thoracic and lung associations); electronic databases; review databases;
internet search engines; grey literature databases and citation searching retrospectively. These
are outlined below.
Search strategy
The search strategy comprised of three stages. Stage 1 used a limited set of key words to
search a small number of guideline clearinghouses and organisational websites to identify
potentially relevant clinical guidelines (e.g. “asthma management guidelines”; “acute asthma
treatment recommendations”) related to adult asthma management. Similarly a limited
set of free text key words were used to search the database MEDLINE to identify potentially
relevant clinical guidelines related to adult asthma management. A brief review of the retrieved
guidelines was conducted in an effort to expand key words and phrases for a more in-depth
search. Prior to progressing the second search strategy stage, finalised search terms with the
nominated contact points for the HSE Asthma Guideline Development Group (GDG) and DoH
CEU were agreed. Stage 2 repeated stage 1 searches and expanded these searches to other
guideline resources (i.e. guideline clearinghouses and grey literature) and other databases (i.e.
PUBMED, CINAHL, Cochrane) using the full list of key words (both free text and the databases
controlled vocabulary e.g. MeSH, Subject Headings etc.) developed in Stage 1. Stage 3 of the
search entailed searching the reference lists of retrieved eligible guidelines. All searches were
conducted and outputs cross-checked by at least 2 or more members of the review team.
Search sources
The following electronic guideline clearinghouses were searched using various key words
specific to adult acute asthma management and clinical practice guidelines; United States
National Guideline Clearinghouse and Guidelines International Network. See Appendix 3.
The following organisations which develop guidelines and/or support evidence based practice
were also searched; the Scottish Intercollegiate Guidelines Network; the National Institute for
Health and Clinical Excellence; the New Zealand Guideline Group; the Centre for Clinical
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(aged 16 years and older) 15
Effectiveness Australia; the National Health and Medical Research Council (Australia); the
Clinical Practice Guideline Portal and the TRIP database. See Appendix 3.
Other specific grey literature sites searched were the Agency for Healthcare Research and
Quality and Open Grey. See Appendix 3.
The electronic databases of PubMed, MEDLINE, CINAHL and review databases of Cochrane
(inclusive of Cochrane Database of Systematic Review; Database of Abstracts of Review Effects)
and NHS Centre for Reviews and Dissemination were searched using various combinations of
controlled vocabulary and free text words. See Appendix 3.
Finally, internet engines including Google, Bing and Yahoo/AltaVista were searched using key
search terms focused on acute asthma management in adults. If available, these searches
were all narrowed to the English language and limited to the file type pdf. As large volumes
of data return through search engine searches, screening was managed by screening the
first 10 pages (i.e. 100 pdf files on each internet search engine). These internet searches were
completed after all other searches and essentially any guidelines that had not already retrieved
from other sources were looked for. See Appendix 3.
Search outputs
The final outputs of the search strategies and screening for eligibility for inclusion in the review
are outlined in Figure 2 below. A total of 2,967 potentially eligible documents were retrieved
for screening across all data sources. After stage 1 screening, 2,915 documents were excluded
because they were not specific to asthma; not systematic evidence based guidelines; not
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
16 (aged 16 years and older)
national/international guidelines; not adult populations; published before 2011 and/or were
duplicates. Thus, 53 documents were identified as potentially eligible for inclusion. Following
second screening a further 49 documents were excluded because they were either duplicates,
not a clinical practice guideline; not a national/international guideline; they were based on
other guidelines such as BTS/SIGN (8) or GINA (14) and/or they had no/limited reporting on
methodology in terms of how guidelines were developed and/or grading of evidence. A total
of 4 clinical practice guidelines were retrieved and deemed potentially eligible for inclusion in
the review; including SIGN 141 British guideline on the management of asthma (British Thoracic
Society and Scottish Intercollegiate Guidelines Network – BTS/SIGN updated 2015)(8); the Global
Strategy for Asthma Management and Prevention (Global Initiative for Asthma - GINA updated
2015) (14); the Consensus Statement for the diagnosis and management of asthma from the
Canadian Thoracic Society (updated 2012) (15) and the Australian Asthma Handbook from the
National Asthma Council Australia (updated 2015) (16).
Following discussion with the Asthma Guideline Development Group and further screening of
these 4 potentially eligible clinical documents a decision was made to exclude the Consensus
Statement for the diagnosis and management of asthma from the Canadian Thoracic Society
(updated 2012)(15) and the Australian Asthma Handbook from the National Asthma Council
Australia (updated 2015)(16). Reasons for exclusion were the lack of specific focus on the
management of acute asthma and missing data to enable us to assess the guideline according
to the review criteria. Therefore 2 clinical practice guidelines were left for inclusion in the
review – the SIGN 141 British guideline on the management of asthma (British Thoracic Society
and Scottish Intercollegiate Guidelines Network – BTS/SIGN updated 2015) (8) and the Global
Strategy for Asthma Management and Prevention (Global Initiative for Asthma - GINA updated
2015) (14). The decision to include both of these guidelines in the review was strengthened by
their currency; both guidelines had been updated in 2015. Secondary citation searching of both
these guidelines was completed and no further clinical practice guidelines were identified for
inclusion in the review.
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
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For phase (ii) each appraisal member was given access to the second guideline eligible for
inclusion in the review (i.e. GINA) and a second online group appraisal was set up via the
MY AGREE PLUS online tool. All 4 appraisers individually scored the GINA guideline (14). Once
completed the scores of all the completed AGREE II Instruments were calculated on MY AGREE
PLUS, entered into a spreadsheet and transferred into a graphical format to enable ease of
comparison of guidelines appraisals across the various quality assessment domains in terms
of overall scores and inter-rater agreement (Appendix 9). Following both phases (i and ii), the
appraisal review team met, in conjunction with the DoH CEU, to discuss the results and any
discrepancies in ratings (especially for ratings > score of 1 difference) were resolved through
discussion. Across both the BTS/SIGN (8) and GINA (14) guidelines, the main domains where some
differences in ratings existed were domain 2 stakeholder involvement (item 4, 5); domain 3 rigour
of development (items 8, 10, 11, 13), domain 5 applicability (items 18, 19, 20, 21) and domain
6 (items 22, 23). Most discrepancies were the result of different interpretations of the rating
criteria and considerations and/or data not been sourced, which were easily resolved through
discussion among the 4 appraisers with the CEU acting as arbitrator if required. Following these
discussions, the group appraisals were revised (Appendix 9) and an overall group consensus
appraisal score was calculated as presented in Appendix 10.
Figure 3 below illustrates the overall group consensus ratings for all items across all domains for
the BTS/SIGN (8) guideline. It was agreed that 19 of the 23 items achieved a maximum rating of 7;
the exceptions were items 5, 18, 19, and 20. Item 5 falls under domain 2 stakeholder involvement
and relates specifically to the views and preferences of the target population. While there was
evidence of this within the BTS/SIGN guideline (8) the explicit process and methods used to
gather patient/public views was not outlined, and/or what and how the information gathered
was used to inform the guideline development process and the recommendations; therefore
a rating of 6 was agreed to take account of this missing information. Items 18, 19 and 20 all
belong to domain 5 which relates specifically to applicability - how the guidelines might be
implemented in practice including facilitators and barriers; tools to facilitate application; and
resource and cost implications. There was limited information on all these items in the BTS/SIGN
guideline (8) and/or supporting documents and thus ratings ranging from 4-5 were agreed for
these items. Figure 4 below illustrates the overall group consensus ratings for all items across all
domains for the GINA (14) guideline. It was agreed that 10 of the 23 items achieved a maximum
rating of 7; the exceptions were items 2, 3, 4, 5, 6, 8, 9, 10, 13, 17, 18, 20 and 21. Of these items 3,
4, 6, 8, 9, 10, 17 achieved a score of 6; meaning that the appraisal group felt that some specific
criteria and/or considerations were not explicitly described within the GINA guideline (14) and/
or supporting documents. Of the remaining items, similar to the BTS/SIGN guideline (8), the
appraisal groups sought more specific information on how the views and preferences of the
target population were sought and translated into the recommendations (item 5 with a rating
of 4) and more details on the guideline implementation process, cost and auditing (items 18, 20
and 21 all related to the domain of applicability achieving ratings of 5, 4 and 4 respectively). The
remaining items related to presenting explicit health questions (item 2 rated at 5) and detailing
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the external review process (item 13 rated at 5); while these 2 items were reported the details
were limited and did not meet all the criteria/considerations outlined in AGREE II.
Drawing on the AGREE II instrument the 6 domain scores are independent and should not be
aggregated into a single quality score; rather a quality score is calculated for each of the 6
AGREE II domains. The appraisal group’s consensual quality scores for each of the 6 AGREE II
domains for both BTS/SIGN (8) and GINA (14) guidelines are displayed in Table 3 below. While
these domain scores may be useful in comparing the guidelines the AGREE Consortium has
not set minimum domain scores or patterns of scores across domains to differentiate between
high and low quality but rather recommends that decisions are made by users and guided
by the context in which AGREE II is used (12). On completing the 23 items of the AGREE II, 2
overall assessments of the guideline were made. One required the appraiser to make an overall
judgement on the quality of the guideline and the other asked the appraiser whether he/she
would recommend the guideline for use. The consensus of the guideline appraisal group was
that they would recommend both BTS/SIGN (8) and GINA (14) for use and the overall judgement
on the quality of both BTS/SIGN (8) and GINA (14) is presented in Figure 5 below where a rating of
1 represents ‘lowest possible quality’ whereas a rating of 7 represents ‘highest possible quality’.
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Table 3 Quality Score for each six AGREE II domains for both BTS/SIGN (8) and GINA (14)
Guideline/ Domain 1: Domain 2: Domain 3: Domain 4: Domain 5: Domain 6:
Domain Scope & Stakeholder Rigour of Clarity of Applicability Editorial
Purpose Involvement Development Presentation Independence
Only graded evidence based recommendations were extracted. It is worth noting that there
were some subtle differences in the criteria descriptions that each guideline used in grading the
recommendations and for ease of comparison these are presented in Appendix 11. A particular
point to note when reviewing the extracted recommendations is that the BTS/SIGN guideline (8)
refers to the levels of evidence as GRADES A-D, whereas the GINA guideline (14) uses the word
EVIDENCE to distinguish levels of evidence A-D. Initially, recommendations for each guideline
were extracted into two separate matrixes independently by one review team member – BTS/
SIGN and GINA . These data extraction matrixes were then collated into one matrix combining
the context/topic areas and recommendations from both guidelines (BTS/SIGN and GINA);
however, apart from ‘acute asthma management in pregnancy’ there was limited overlap
on the context/topic areas of the recommendations. All matrixes were cross-checked by
a 2nd reviewer. Discrepancies were resolved by a 3rd reviewer and discussed with the Clinical
Effectiveness Unit (CEU) and the Health Service Executive (HSE) Asthma Guideline Development
Group (GDG). This included; discussions around the applicable recommendations to extract
from the eligible guidelines i.e. recommendations had to be supported by graded evidence
and recommendations had to be specifically related to ‘acute asthma management in adults’.
Following discussions, the recommendation data extraction table was revised as presented in
Appendix 12.
The reviewer consensus ratings for Tool 13 (ADAPTE process) are presented in Appendix 13.
Tool 13 evaluates the search and selection of evidence. There was agreement among the 2
reviewers that the overall search for evidence was comprehensive for both the BTS/SIGN (8) and
GINA guideline (14). Tool 13 also evaluates reviewer’s judgement on the bias in the selection of
articles. For both the BTS/SIGN (8) and GINA (14) guideline, both reviewers found this difficult to
assess but were in agreement in their rating of ‘unsure’; this was as a consequence of limited
reporting of the selection process in relation to the explicit number of references analysed,
included, excluded and reasons for exclusion etc. While it was clear that explicit methodological
processes were followed (17) in the selection and screening of evidence the actual outcomes
were not reported explicitly in the guideline document to make adequate judgements on
whether the overall bias in the selection of articles was avoided.
The reviewer consensus ratings for Tool 14 (ADAPTE process) are presented in Appendix 14.
Tool 14 (ADAPTE process) evaluates 3 elements; whether the overall evidence is considered
valid; whether the evidence and recommendations are coherent; and whether the scientific
quality of the recommendations pose any risk of bias. For both the BTS/SIGN (8) and GINA (14)
guideline, both reviewers agreed that the overall evidence was valid, the evidence presented
throughout both guideline documents was mapped coherently to the recommendations and
overall it was agreed the scientific quality of the recommendations of both the BTS/SIGN (8) and
GINA (14) guidelines did not present risks of bias with the strength of the evidence attributed
to each recommendation being adequately described, justified and clearly presented in both
guidelines. Refer to Appendix 14.
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
22 (aged 16 years and older)
To assist the reader of this guideline, the key to the grading of evidence and recommendations
is as follows:
Levels of evidence
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a
moderate probability that the relationship is causal
2 Case control or cohort studies with a high risk of confounding or bias and a significant risk that
the relationship is not causal
4 Expert opinion
Grades of recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation.
A At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to
the target population; or body of evidence consisting principally of studies rated as 1+, directly
applicable to the target population, and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target population,
and demonstrating overall consistency of results; or Extrapolated evidence from studies rated
as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target population
and demonstrating overall consistency of results; or Extrapolated evidence from studies rated
as 2++
√ Recommended best practice based on the clinical experience of the guideline development group
Recommendations within this guideline are based on the best clinical evidence.
This guideline was reviewed in draft form by Prof. Fitzgerald as an independent expert referee,
who was asked to comment primarily on the comprehensiveness and accuracy of interpretation
of the evidence base supporting the guideline and recommendations. Prof. Fitzgerald
agreed with the guideline contents without significant changes. Prof. Fitzgerald’s most recent
declarations of interest are available on www.ginasthma.org.
All hospitals admitting asthma attacks should adopt this standard treatment protocol for the
management of the asthma patient. The treatment care bundles, presented in Appendix 2,
should be held in the patients chart. The care bundles are key to the evaluation and audit of
asthma care process.
These protocols should be adopted by all hospitals who may deal with an asthma attacks in
the course of other procedures, interventions, day surgery, admission, in-patient and out-patient
visits.
A local implementation team with a local lead in each hospital site will facilitate implementation
of the programme and these guidelines. This local lead will act as a champion for the
programme. Whilst this group is not active in each site currently, the NCPA will untertake to
engage with each site to support the establishment and ongoing activities of this group.
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 25
General Practitioners managing acute asthma attacks in primary care should adopt this
standard treatment protocols and bundles for the management of the asthma patient.
The eLearning programme has been approved for CPD credits by ICGP.
The ICGP have developed additional online asthma modules to complement the NCPA
programme. This is recommended for all primary care physicians and physicians-in-training.
It is well documented worldwide that patients with asthma have low expectations of disease
management. They are frequently unaware of the GINA definition of well-controlled asthma
and thus believe that daily wheezing/frequent need for short acting beta 2 agonist (SABA) is
‘normal’. Thus, if patients’ expectations of asthma management remain unchanged they will
not be receptive to training on inhaler technique, education on medication adherence, use of
an asthma action plan etc. This is one of the major barriers to implementation and needs to be
addressed by all healthcare professionals. The introduction of the ‘Under 6s‘ medical card in the
GP under 6s contract in April 2015 is helping to address this issue as it includes an annual ‘Cycle
of Care’ for Asthma assessment and chronic disease management which reflects significant
elements of the Asthma Model of Care of the National Clinical Programme for Asthma. It is
anticipated that a similar approach will be developed for older children and adults asthma in
the near future.
All clinical staff with responsibility for the care of patients with asthma are expected to:
• Comply with this National Clinical Guideline and any related procedures or protocols,
• Adhere to their code of conduct and professional scope of practice as appropriate to their
role and responsibilities, and
• Maintain their competency for the management and treatment of patients with asthma.
The roles and responsibilities of all stakeholders involved in the lifecycle of the guideline are
detailed in the table below (this is not an exhaustive list).
Table 4 Roles and responsibilities of stakeholders in relation to the National Clinical Guideline
General Practitioners 3
Practice Nurses 3
Out of Hours Staff 3
Pharmacist 3
Pre-Hospital emergency care 3
practitioners
ED/AMU Physicians 3
ED/AMU Nursing Staff 3
Specialist Respiratory Teams 3 3 3 3
Clinical Audit Services 3 3
National Clinical Programme for 3 3 3
Asthma
Patient Organisation 3
(Asthma Society of Ireland)
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 27
The following Key Performance Indicators will be used to evaluate the implementation of the
guideline:
• Percentage of nurses in primary and secondary care who are trained by the National
Asthma Programme
• Number of deaths caused by asthma annually
As the process of implementation continues the National Clinical Programme for Asthma will
endeavour to expand the audit criteria.
At a local level, audit of the use of the treatment protocols will be carried out by Emergency/
Acute Medicine / Respiratory teams. The ED, AMU, Medical ward will retain a copy of the
treatment bundle administered on file and make a copy available to assist them with audit. This
will serve a dual function:
This note should be read alongside Recommendations 16 and 18 and their preceding texts.
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
28 (aged 16 years and older)
1. Healthcare professionals must be aware that patients who present with a severe asthma
B
attack and one or more adverse psychosocial factors are at risk of death.
B 2. Clinicians in primary and secondary care should treat asthma attacks according to
recommended guideline.
B 3. Refer patients to hospital who display any features of acute severe or life threatening asthma.
B 4. Admit patients to hospital with any feature of a life threatening or near fatal attack.
B 5. Admit patients to hospital with any feature of a severe attack persisting after initial treatment.
C 6. Admit patients to hospital whose peak flow is less than 75% best or predicted after initial
treatment.
C 7. Patients whose peak flow is greater than 75% best or predicted one hour after initial treatment
may be discharged from ED unless they meet any of the following criteria, when admission
may be appropriate:
• still have significant symptoms
• concerns about adherence
• living alone/socially isolated
• psychological problems
• physical disability or learning difficulties
• previous near-fatal asthma attack
• asthma attack despite adequate dose steroid tablets pre-presentation
• presentation at night
• pregnancy.
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 29
C 8. Give supplementary oxygen to all A 11. Adults with mild and moderate attacks
hypoxaemic patients with acute of asthma should be treated by pMDI +
asthma to maintain an SpO2 level spacer with doses titrated according to
of 94-98%. Lack of pulse oximetry clinical response.
should not prevent the use of A 12. In hospital, ambulance and primary care,
oxygen. nebulised β2 agonist bronchodilators should
A 9. In hospital, ambulance and preferably be driven by oxygen.
primary care, nebulised β2 agonist A 13. Consider continuous nebulisation in patients
bronchodilators should be driven with severe asthma who respond poorly to
by oxygen. an initial bolus dose of β2 agonist, using an
C 10. The absence of supplemental appropriate nebulizer.
oxygen should not prevent A 14. In acute asthma with life threatening
nebulised β2 agonist therapy being features the nebulised route (oxygen-
given if indicated. driven) is recommended.
A 15. Use high dose inhaled β2 agonists as first line
agents in acute asthma and administer as
early as possible. Reserve intravenous β2
agonists for those patients in whom inhaled
therapy cannot be used reliably.
A 16. Give steroids in adequate doses in B 17. Add nebulised ipratropium bromide (0.5
all cases of acute asthma. mg 4-6 hourly) to β2 agonist treatment
for patients with acute severe or life
3 Continue oral prednisolone 40mg daily threatening asthma or those with a poor
for at least 5 days or until recovery. initial response to β2 agonist therapy.
B 18. Consider giving a single dose of IV magnesium sulphate for patients with:
• Acute severe asthma who have not had a good initial response to inhaled
bronchodilator therapy
• Life threatening or near fatal asthma.
3 IV Magnesium sulphate (1.2 - 2g IV infusion over 20 minutes) should only be used following
consultation with senior medical staff.
B 19. Routine prescription of antibiotics is not indicated for patients with acute asthma.
B 20. Heliox is not recommended for use in acute asthma outside a clinical trial setting.
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
30 (aged 16 years and older)
C 22. All patients transferred to intensive care units should be accompanied by a doctor suitably
equipped and skilled to intubate if necessary.
3 Patients with acute asthma should not be sedated unless this is to allow anaesthetic or intensive
care procedures.
C 23. Give drug therapy for acute asthma as for the non-pregnant patient including systemic
steroids and magnesium sulphate.
D 24. Deliver high flow oxygen immediately to maintain oxygen saturation between 94-98%.
A 25. Discharge from hospital or ED should be a planned, supervised event which includes self-
management planning. It may safely take place as soon as clinical improvement is apparent
A 26. Prior to discharge, in patients should receive written personalised action plans, given by
clinicians with expertise in asthma management
B 27. Prescribe inhalers only after the patient has received training in the use of the device and
has demonstrated satisfactory technique
A 28. All people attending hospital with acute attacks of asthma should be reviewed by a
clinician with particular expertise in asthma management, preferably within 30 days
severe asthma, in a minority the fatal attack has occurred suddenly in a patient with mild or
moderately severe background disease. Most asthma deaths occur before admission to hospital.
Many deaths occur due to patients receiving inadequate treatment with inhaled steroids or
steroid tablets and/or inadequate objective monitoring of their asthma, where follow up was
inadequate in some and others should have been referred earlier for specialist advice (10).
Level of evidence 2++ (BTS/SIGN 2014)
“Studies comparing near-fatal asthma with deaths from asthma have concluded that patients
with near-fatal asthma have identical adverse factors to those described above and that
these contribute to the near-fatal asthma attack. Compared with patients who die, those with
near-fatal asthma are significantly younger, are significantly more likely to have had a previous
near-fatal asthma attack, are less likely to have concurrent medical conditions, are less likely
to experience delay in receiving medical care, and more likely to have ready access to acute
medical care.”
Level of evidence 2+ (BTS/SIGN 2014)
“With near-fatal asthma it is advisable to involve a close relative when discussing future
management.” (BTS/SIGN 2014)
All personnel who may be in contact with a patient with an acute asthma attack e.g. GP
practice receptionists, pre-hospital emergency care practitioners and responders, out of hours
staff and community pharmacists, should be aware that asthma patients complaining of
respiratory symptoms may require immediate access to a physician or a nurse trained in acute
asthma management as they may deteriorate suddenly.
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
32 (aged 16 years and older)
Patients’ with asthma should have an agreed guided written asthma management plan - this
can be disscussed during the follow-up after discharge. They should know when and how to
increase their medication and when to seek medical assistance if their asthma is not controlled.
Agreed treatment steps should be clearly illustrated within the written asthma management
plan. Such plans can decrease acute asthma, hospitalisation and deaths from asthma.
Patients should know when and how to increase their medication and when to seek medical
assistance. This should be contained within the written asthma management plan with treatment
steps clearly illustrated. Such plans can decrease hospitalisation for and deaths from asthma.
De-escalating treatment steps must also be outlined in management plan once acute episode
is resolved.
All personnel who may be in contact with a patient with an acute asthma attack e.g. GP
practice receptionists, pre-hospital emergency care practitioners and responders, out of hours
staff and community pharmacists, should be aware that asthma patients complaining of
respiratory symptoms should have immediate access to a physician or a nurse trained in acute
asthma management as they may deteriorate rapidly.
“The assessments required to determine whether the patient is suffering from an acute attack
of asthma, the severity of the attack and the nature of treatment required are detailed in this
guideline. It may be helpful to use a systematic recording process. Proformas such as protocols
and care bundles in Appendix 2 have proved useful in acute asthma management”
(BTS/SIGN 2014)
The vast majority of acute asthma attacks are managed at Primary Care level including GP Out
of Hours (GPOOH) settings. These attacks are characterised by worsening symptoms including
shortness of breath, cough, wheezing or chest tightness, or a combination of these symptoms.
It is important to be aware that patient’s symptoms may underestimate the severity of the attack
and to have objective measurements of the event, to include:
• Peak expiratory flow (PEF) or FEV1
• Respiratory rate
• Heart rate
• Oxygen saturation (when available)
The severity of asthma exacerbation can be categorised according to the algorithms included
in this guideline (see Appendix 2).
√ GP support is required to allow patients who are seen in an acute event to be followed up and offered
structured care and education. This may involve making contact per phone or flagging notes when
patient attends again for any reason including repeat prescriptions.
What are the criteria for referral to the Emergency Department for patient with an acute asthma
attack?
Protocols for the emergency treatment of asthma attacks in the pre-hospital setting can be
found on the Pre-Hospital Emergency Care Council (PHECC), www.phecc.ie, and are replicated
in Appendix 2.
What are the Hospital Admission Criteria with an acute asthma attack?
Admit patients with any feature of a severe asthma attack persisting after initial treatment.
Patients whose peak flow is greater than 75% best or predicted one hour after initial treatment
may be discharged from ED unless they meet any of the following criteria, when admission may
be appropriate:
• still have significant symptoms
• concerns about adherence
• living alone/socially isolated
• psychological problems
• physical disability or learning difficulties
• previous near-fatal asthma attack
• asthma attack despite adequate dose steroid tablets pre-presentation
• presentation at night
• pregnancy.
(BTS/SIGN 2014)
Asthma attacks (attacks of acute asthma) are associated with progressive increase in
asthma symptoms (typically, shortness of breath (SOB), cough, wheeze, chest tightness or any
combination of these) but the patient’s own perception of asthma symptoms in some cases
may be poor and thus unreliable. In addition to symptoms there is usually an objective decrease
in expiratory flow rates on lung function testing. This should be quantified by PEF or spirometry
(FEV1). The PEF or FEV1 expressed as percentage (%) of personal best is the most useful clinically
but in the absence of this the % predicted value is a rough guide. Of note a reduction to 50% or
less from predicted or best values indicates a severe attack. Pulse oximetry can be of use as low
oxygen levels may indicate the necessity for referral to hospital but normal levels greater than
92% do not exclude a severe asthma attack. These measures along with history, examination,
pulse and respiratory rate and response to treatment are all required to determine the need for
hospitalisation or risk of relapse after acute management. The assessment and management
should follow the guidelines outlined in the following acute asthma management protocols.
Recognition of acute asthma is done by assessing the level of severity of the patient and this
includes the clinical history, examination, (including chest, pulse and respiration rates), peak
flow rates (PEF) with peak flow meter and oxygen saturation (SpO2) with a pulse oximeter.
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 35
Delay in treatment and under-dosing in an asthma attack can adversely affect outcomes. By
using objective measures, the level of asthma severity is less likely to be underestimated. This will
enable prompt treatment at the right dose to be effective.
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
36 (aged 16 years and older)
Clinical features
“Clinical features can identify some patients with severe asthma, e.g. severe breathlessness
(including too breathless to complete sentences in one breath), tachypnea, tachycardia, silent
chest, cyanosis, accessory muscle use, altered consciousness or collapse. None of these singly
or together is specific. Their absence does not exclude a severe attack.”
Level of evidence 2+ (BTS/SIGN 2014)
What are the key components of an objective assessment of an attack in the adult asthma
patient?
Pulse oximetry
Good clinical practice would support a measure of oxygen saturation (SpO2) with a pulse
oximeter to determine the adequacy of oxygen therapy and the need for arterial blood gas
(ABG) measurement. The aim of oxygen therapy is to maintain SpO2 94-98%. In hypoxic patients
it is important to consider alternative diagnosis e.g. Pneumothorax or pneumonia.
PEF or FEV1
“Measurements of airway calibre improve recognition of the degree of severity, the
appropriateness or intensity of therapy, and decisions about management in hospital or at
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 37
home. PEF or FEV1 are useful and valid measures of airway calibre. PEF is more convenient in
the acute situation. PEF expressed as a percentage of the patient’s previous best value is most
useful clinically. PEF as a percentage of predicted gives a rough guide in the absence of a
known previous best value. Different peak flow meters give different readings. Where possible
the same or similar type of peak flow meter should be used.”
Level of evidence 2+ (BTS/SIGN 2014)
Chest X-ray
“Good clinical practice suggests that a Chest X-ray is not routinely recommended in patients
with an asthma attack in the absence of:
• suspected pneumomediastinum or pneumothorax
• suspected consolidation
• life threatening asthma
• failure to respond to treatment satisfactorily
• requirement for ventilation”
Level of evidence 4 (BTS/SIGN 2014)
Blood gases
“Patients with SpO2 less than (<) 92% (irrespective of whether the patient is on air or oxygen)
or other features of life threatening asthma require ABG measurement. SpO2 less than 92% are
associated with a risk of hypercapnea (raised blood CO2). Hypercapnea is not detected by
pulse oximetry. In contrast the risk of hypercapnea with SpO2 greater than 92% is much less.”
Level of evidence 2+ and 4 (BTS/SIGN 2014)
What is the best practice treatment of the adult asthma patient during an acute attack?
The primary therapies for the management of an attack to relieve airflow obstruction and
hypoxemia include:
• Repetitive administration of rapid-acting inhaled β2 agonist bronchodilator via pMDI with
spacer or O2 driven nebuliser
• Early introduction of systemic glucocorticosteroids
• Oxygen supplementation
• (The clinician may decide if antibiotic therapy is appropriate in some cases)
Oxygen
“Many patients with acute severe asthma are hypoxemic (low blood oxygen). Supplementary
oxygen should be given urgently to hypoxemic patients, using a face mask, Venturi mask or
nasal cannula with flow rates adjusted as necessary to maintain SpO2 of 94-98%.” (BTS/SIGN
2014)
“Hypercapnea (raised blood CO2 levels) indicates the development of near-fatal asthma and
the need for emergency specialist/anaesthetic intervention”.
Level of evidence 2+, 4 (BTS/SIGN 2014)
In acute asthma without life threatening features, “β2 agonists can be administered by repeated
activations of a pressurised metered dose inhaler (pMDI) via an appropriate large volume spacer
or by wet nebulisation driven by oxygen, if available. Inhaled β2 agonists are as efficacious and
preferable to intravenous β2 agonists (meta-analysis has excluded subcutaneous trials) in adult
acute asthma in the majority of cases. Metered dose inhalers with spacers can be used for
patients with attacks of asthma other than life threatening” (BTS/SIGN 2014). The bronchodilator
therapy delivered via metered-dose inhaler pMDI, ideally with a spacer, produces at least an
equivalent improvement in lung function as the same dose delivered via nebulizer. This route
of delivery is the most cost effective, provided patients are able to use an pMDI with spacer
assistance.
Mild/Moderate attacks: give up to 12 puffs via spacer, one at a time and inhaled separately.
Assess after 10-20 minutes. Repeat as necessary (3 doses in total). No additional medication
is necessary if the rapid-acting inhaled β2 agonist produces a complete response (FEV1 or PEF
returns to greater than 80% of predicted or personal best) and the response lasts for 3 to 4 hours.
“The absence of supplemental oxygen should not prevent nebulised therapy from being
administered when appropriate”.
Level of evidence 4 (BTS/SIGN 2014)
“Parenteral β2 agonists, in addition to inhaled β2 agonists, may have a role in ventilated patients
or those in extremis; however there is limited evidence to support this”. (BTS/SIGN 2014)
“Most cases of acute asthma will respond adequately to bolus nebulisation of β2 agonists.
Continuous nebulisation of β2 agonists with an appropriate nebuliser may be more effective than
bolus nebulisation in relieving acute asthma for patients with a poor response to initial therapy”.
Level of evidence 1+ (BTS/SIGN 2014)
“In acute asthma without life threatening features, β2 agonists can be administered by repeated
activations of a pMDI via an appropriate large volume spacer or by wet nebulisation driven
by oxygen, if available. Inhaled β2 agonists are as efficacious and preferable to intravenous β2
agonists (meta-analysis has excluded subcutaneous trials) in adult acute asthma in the majority
of cases”.
Level of evidence: 1 ++ (BTS/SIGN 2014)
“Metered dose inhalers with spacers can be used for patients with attacks of asthma other than
life threatening.”
Level of evidence 1++ (BTS/SIGN 2014)
Steroids (Glucocorticosteroids)
“Steroids reduce mortality, relapses, potential hospital admission and requirement for β2 agonist
therapy. The earlier they are given in the acute attack the better the outcome”.
Level of evidence 1++ (BTS/SIGN 2014)
“Steroid tablets are as effective as injected steroids, provided they can be swallowed and
retained. Oral prednisolone 40-50 mg daily or parenteral (IV) hydrocortisone 400 mg daily (100
mg six-hourly) is as effective as higher doses. For convenience, steroid tablets may be given as
2 x 25 mg tablets daily rather than 8 - 10 x 5 mg tablets. Where necessary soluble prednisolone
(sodium phosphate) 5 mg tablets can be used. In cases where oral treatment may be a problem
consider intramuscular (IM) methylprednisolone 160 mg as an alternative to a course of oral
prednisolone (this is likely to be a large 4mls injection).”
Level of evidence: 1++ (BTS/SIGN 2014)
“Following recovery from the acute attack steroids can be stopped abruptly. Good practice
indicates that doses do not need tapering provided the patient receives inhaled steroids
(caution is required for patients on maintenance steroid treatment or rare instances where
steroids are required for three or more weeks)”.
Level of evidence 1+ (BTS/SIGN 2014)
In addition to systemic (oral, IV, or IM) steroids, inhaled steroids should be continued (or started if
not already prescribed) and commence the chronic asthma management plan.
Level of evidence 1+ (BTS/SIGN 2014)
Ipratropium bromide
“Combining nebulised ipratropium bromide with a nebulised β2 agonist produces significantly
greater bronchodilation than a β2 agonist alone, leading to a faster recovery and shorter dura-
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 41
tion of admission. Anticholinergic treatment is not necessary and may not be beneficial in milder
attacks of asthma or after stabilisation”.
Level of evidence 1++ (BTS/SIGN 2014)
Magnesium sulphate
“There is some evidence that, in adults, magnesium sulphate has bronchodilator effects.” (BTS/
SIGN 2014). Experience suggests that magnesium is safe when given by the intravenous (IV) or
nebulised route. Trials comparing these routes of administration are awaited. Studies report the
safe use of nebulised magnesium sulphate, in a dose of 135 mg - 1152 mg, in combination with
β2 agonists, with a trend towards benefit in hospital admission. “A single dose of IV magnesium
sulphate is safe and may improve lung function in patients with acute severe asthma” (BTS/SIGN
2014).
Level of evidence 1++ (BTS/SIGN 2014)
“The safety and efficacy of repeated IV doses has not been assessed. Repeated doses could
cause hypermagnesaemia with muscle weakness and respiratory failure.” (BTS/SIGN 2014)
More studies are needed to determine the optimal route, frequency and dose of magnesium
sulphate therapy.
Good practice indicates that it should only be given on the advice of a senior physician.
However, in acute asthma, “IV aminophylline is not likely to result in any additional
bronchodilation compared to standard care with inhaled bronchodilators and steroids. Side
effects such as arrhythmias and vomiting are increased if IV aminophylline is used.”
Level of evidence 1++ (BTS/SIGN 2014)
“Some patients with near-fatal asthma or life threatening asthma with a poor response to initial
therapy may gain additional benefit from IV aminophylline (5 mg/kg loading dose over 20
minutes unless on maintenance oral therapy, then infusion of 0.5-0.7 mg/kg/hr). Such patients
are probably rare and could not be identified in a meta-analysis of trials. If IV aminophylline
is given to patients on oral aminophylline or theophylline, blood levels should be checked on
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
42 (aged 16 years and older)
admission. Levels should be checked daily for all patients on aminophylline infusions.” (BTS/SIGN
2014)
Antibiotics
Antibiotics should not be given automatically unless there is strong suspicion of bacterial
infection, elevated temperature, raised white cell count, infiltrate on chest x-ray or copious
green phlegm and should be guided by local microbiology guidelines.
“When an infection precipitates an asthma attack it is likely to be viral. The role of bacterial
infection in an attack has been overestimated.”
Level of evidence 1++ (BTS/SIGN 2014)
Intravenous fluids
There are no controlled trials, observational or cohort studies of IV fluid regimes in acute asthma.
Good practice point
√ Some patients with acute asthma require rehydration and correction of electrolyte imbalance.
Hypokalaemia can be caused or exacerbated by β2 agonist and/or steroid treatment and must be
corrected. (BTS/SIGN 2014)
Heliox
“The use of heliox, (helium/oxygen mixture in a ratio of 80:20 or 70:30), either as a driving gas
for nebulisers, as a breathing gas, or for artificial ventilation in adults with acute asthma is not
supported on the basis of present evidence. A systematic review of ten trials (554 patients),
including patients with acute asthma, found no improvement in pulmonary function or other
outcomes in adults treated with heliox, although the possibility of benefit in patients with more
severe obstruction exists. Heliox requires the use of specifically designed or modified breathing
circuits and ventilators.”
Level of evidence 1++, 1+ (BTS/SIGN 2014)
Nebulized furosemide
“Although theoretically furosemide may produce bronchodilation, a review of three small trials
failed to show any significant benefit of treatment with nebulised furosemide compared to β2
agonists”.
Level of evidence; 1+ (BTS/SIGN 2014)
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 43
ICU/HDU
“Indications for admission to intensive care or high-dependency units include patients requiring
ventilator support and those with severe acute or life threatening asthma who are failing to
respond to therapy, as evidenced by:
• deteriorating PEF
• persisting or worsening hypoxia
• hypercapnea
• arterial blood gas analysis showing fall in pH or rising H+ concentration
• exhaustion, feeble respiration
• drowsiness, confusion, altered conscious state
• respiratory arrest.
Not all patients admitted to the Intensive Care Unit (ICU) need ventilation, but those with
worsening hypoxia or hypercapnea, drowsiness or unconsciousness and those who have had
a respiratory arrest require intermittent positive pressure ventilation. Intubation in such patients
is very difficult and should ideally be performed by an anaesthetist or ICU consultant” (BTS/
SIGN 2014). Treatment has to be adjusted periodically in response to worsening control, which
may be recognised by the minor recurrence or worsening of symptoms following treatment for
an attack, maintenance treatment can be resumed at previous levels unless the attack was
associated with a gradual loss of control suggesting chronic under treatment.
Level of evidence; 2+ (BTS/SIGN 2014)
Structured proforma
“The use of structured proformas facilitates improvements in the process of care in emergency
departments and hospital wards and improves patient outcomes. The use of this type of
documentation can assist data collection aimed at determining quality of care and outcomes”.
Level of evidence: 2 + (BTS/SIGN 2014)
“Prednisolone is extensively metabolised in the placenta such that only 10% reaches the fetus”
(BTS/SIGN 2014). Steroid therapy in the first trimester may be associated with an increased risk
of oral clefts in the fetus. However, women should be advised that if required, the benefits of
treatment with oral steroids for asthma attacks outweigh the risks thereof.
It is important that treatment with steroids should not be withheld if indicated for the management
of an asthma attack because of pregnancy.
The inhaled short acting β2 agonist, salbutamol, is recommended rescue therapy for pregnant
women with asthma. No significant association has been demonstrated between major
congenital malformations or perinatal outcomes and exposure to short acting β2 agonists.
4. Consider intensive care medicine consult with senior anaesthetist and need for possible
intubation and ventilation for those patients with deteriorating condition.
5. Continuous fetal monitoring is recommended in cases of severe or life threatening acute
asthma presentation.
6. If a patient with LIFE THREATENING ASTHMA requires delivery this should be performed by
an obstetric team in a general hospital with ICU and respiratory physician back up.
7. A patient with a SEVERE/MODERATE asthma attack not improved by initial nebulizer and
oxygen treatment should be immediately transferred to a general hospital with ICU facilities.
8. CXR*/ECG/ABG should be performed in patients presenting with acute asthma attack
(except where the presentation is MILD).
* use abdominal shielding and defer unless deemed urgent in the first trimester.
9. Respiratory physician input should be sought regarding the ongoing management of
pregnant patients admitted to a maternity hospital with an asthma attack. A consultation
with a respiratory physician to advise on further treatment options and follow up on
discharge.
10. Patients presenting with an acute asthma attack in pregnancy should be followed up on
discharge with the respiratory service to reduce incidence of further attack in pregnancy.
11. Consideration for other pathologies should be given for women presenting in pregnancy
with respiratory symptoms similar to acute asthma including those who do not have a
history of asthma. Pulmonary embolism, pulmonary oedema secondary to pre-eclampsia,
puerperal cardiomyopathy, pneumonia, ischemic or valvular heart disease may also
present with shortness of breath, hypoxia or respiratory wheeze.
What role can patient education play in asthma management following an acute asthma
attack?
“Following discharge from hospital or emergency departments, a proportion of patients re-
attend. International data has shown that more than 15% re-attended within two weeks. Some
repeat attenders need emergency care, but many delay seeking help, and are under-treated
and/or under-monitored”.
Level of evidence 2+ (BTS/SIGN 2014)
“Prior to discharge, trained staff should give asthma education. This should include education
on inhaler technique and PEF performance and record keeping. A written PEF and symptom-
based action plan should be provided allowing the patient to adjust their therapy within agreed
parameters. These measures have been shown to reduce morbidity after the attack and reduce
relapse rates”.
Level of evidence 1++ (BTS/SIGN 2014)
“There is some experience of a discrete population of patients who use emergency departments
rather than primary care services for their asthma care. Education has been shown to reduce
subsequent hospital admission and improve scheduled appointments and self management
techniques but does not improve re-attendance at emergency departments”. (BTS/SIGN 2014)
“For the above groups there is a role for a trained asthma liaison nurse based in, or associated
with, the emergency department.”
Level of evidence 1++ (BTS/SIGN 2014)
All patients following an asthma attack should be educated in the management of their
condition which can be provided by healthcare professionals trained in asthma management.
This should include;
• Awareness of triggers and symptoms of onset of attack
• Medications compliance
• Inhaler technique (see www.hse.ie, www.irishthoracicsociety.com, www.asthmasociety.ie
for copies of checklists)
• Peak flow technique and diary recording
• Asthma Management Plan (see Appendix 2.5)
People requiring further supports prior to discharge should be referred to appropriate services.
Such patients include:
• Those who live alone or are socially isolated
• Those who have behavioral or psychological problems
• Substance misuse
• Those who have a physical disability or learning difficulties
• Those who are currently on sedatives or psychiatric medication
“Prior to discharge, trained staff should give asthma education. This should include education
on inhaler technique and PEF performance and record keeping. A written PEF and symptom-
based action plan should be provided allowing the patient to adjust their therapy within agreed
parameters. These measures have been shown to reduce morbidity after the attack and reduce
relapse rates”.
Level of evidence 1++ (BTS/SIGN 2014)
“There is some experience of a discrete population of patients who use emergency departments
rather than primary care services for their asthma care. Education has been shown to reduce
subsequent hospital admission and improve scheduled appointments and self management
techniques but does not improve re-attendance at emergency departments.” (BTS/SIGN 2014)
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 47
“For the above groups there is a role for a trained asthma liaison nurse based in, or associated
with, the emergency department.”
Level of evidence 1++ (BTS/SIGN 2014)
It is recommended that follow up be arranged prior to discharge with the patient’s general
practitioner or asthma nurse / hospital specialist asthma/respiratory service as follows:
• The appropriate General Practice should be informed and receive appropriate discharge
summary by fax / email within 24 hours of the patient’s discharge
• Before discharge the patient should be instructed to arrange an appointment with their GP
or practice nurse within 2 working days of discharge.
• A requisition for a follow-up appointment with a hospital asthma / respiratory service should
be made within 4 weeks of the episode.
“Assisting patients in making appointments while being treated for acute asthma in emergency
departments may improve subsequent attendance at primary care centres.”
Level of evidence 1+ (BTS/SIGN 2014)
2.2. Emergency Treatment Care Bundles for Management of Acute Adult Asthma
• Management of asthma attack in general practice care bundle
• Life Threatening Asthma Attack Care bundle
• Severe/Moderate Asthma Attack Care Bundle
• Asthma Patient Discharge Care Bundle
2.3. Discharge Letter, Fax, Email Template for Management of Acute Adult Asthma
Appendix 2.1 Emergency treatment protocols for management of acute adult asthma
Management of acute
Management adult
of Acute asthma
Adult Asthmain ED,
in ED, AMU
AMU and & In Hospital
in Hospital
Initial Assessment
Look for LIFE THREATENING FEATURES - take history, physical examination (auscultation, use of accessory
muscles, heart rate, respiratory rate, PEF, or FEV1, oxygen saturation, arterial blood gas if patient in extremis)
PEF < 33% best or predicted PEF 33–50% best or predicted PEF 50-75% best or PEF >75% best or
SpO2 <92% OR any one of the SpO2 >92% predicted predicted
SpO2 >92% SpO2 >92%
Life Threatening Asthma Features: Severe Moderate Mild
Silent chest, cyanosis, poor PEF <50% (severe) - Loud wheeze - Can lie down
respiratory effort Respiration >25 breaths/min - Prefer to sit - Talks in sentences
Bradycardia, arrhythmia, Pulse > 110 beats/min - Talks in phrases - Mild-Mod wheeze
Check BP for hypotension Cannot complete sentence in one - PR<110 Beats/ min - PR<100 Beats/ min
Exhaustion, confusion, coma breath - RR<25 Breaths/ min - RR<25 Breaths/ min
BP Normal - BP Normal - BP Normal
ADMIT for minimum of 24 hours Signs of severe Patient Stable Start on inhaled
Patient should be accompanied by a asthma AND PEF >50% Steroids
nurse or doctor at all times OR PEF <50%
4/5/6.3.4
Version 2, 05/14 Asthma – Adult EMT P
Asthma/ AP
bronchospasm
Assess and maintain airway
Respiratory assessment
Mild Asthma OR
Salbutamol If no improvement Salbutamol
(0.1 mg) metered aerosol aerosol, 0.1 mg may be repeated
up to 5 times as required
Resolved/
Yes
improved
No
Oxygen therapy
Request
ALS
Resolved/
Yes
improved
No
Resolved/
Yes
improved
No
Resolved/
Yes
improved
No
Life-threatening Consider
Asthma Magnesium Sulphate 2 g IV
(infusion in 100 mL NaCl)
Reference: HSE National Asthma Programme 2012, Emergency Asthma Guidelines, British Thoracic Society, 2008, British Guidelines on the Management
of Asthma, a national clinical guideline
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
56 (aged 16 years and older)
Appendix 2.2 Emergency treatment care bundles for management of acute adult asthma
Adult Asthma Acute Management in General Practice and Primary Care out of hours settings
Assess and Record: Peak expiratory flow; Symptoms and response to self treatment; Heart and respiratory
rates; Oxygen Saturation (by pulse oximetry, if available)
Caution: Patients with severe or life threatening attacks may not be distressed and may not have all the
abnormalities listed below. The presence of any should alert the doctor
Regard each emergency asthma consultation as for acute life threatening/severe asthma until it is
shown otherwise
All patients who received nebulised β2 agonist, require extended observation period
Give high concentration Oxygen (60%) to maintain Sp02 greater than 94%
Assess need for intubation and ventilation, if yes contact anaesthetist/Critical care
team
r
Chest X-Ray
12-lead ECG
_________________________ ___________________________
Review each of the steps and incorporate into your discharge planning process for an Asthma Patient
r If PEF < 50% on presentation, prescribe oral prednisolone 40-50 mg/day for 5 days
r Ensure prescription for oral (if required) and inhaled steroid β2 agonist is supplied to
patient on discharge (GMS patient go to GP for medical card prescription)
r Purchase own PEF meter from Asthma Society of Ireland (ASI) or pharmacy
r Advise patient to arrange GP follow up for within 2 working days of presentation for
moderate/ severe/ life-threatening asthma (within 2 weeks – mild)
_________________________ ___________________________
Appendix 2.3. Discharge letter, fax, email template for management of acute adult asthma
Hospital Name
Address _____________________________________________________________________________________________
We have discussed
r Inhaler use / technique with (type) ……………...........................................…………………………………….
r Medicines including side effects ………………….............................................………………………………….
r Trigger avoidance ……………………………………..................................................………………………………..
r Smoking cessation ……………………………...................................................………………………………………
r How to recognise worsening asthma and what to do in asthma attack: ....................................…
Was given a leaflet detailing a simple management plan (copy enclosed) …...............................……….
……………………………………………………………..........................................................………………………………
Yes No N/A
2. Pulse rate, respiratory rate and SpO2. Where SpO2< 92% check arterial r r r
blood gases and give oxygen as appropriate
Where you have ticked N/A (not applicable) please explain here e.g. No Peak flow as under 5
HOW TO USE YOUR
PEAK FLOW METER Asthma
1. Measure your peak flow morning and evening
before taking your inhalers. Management Plan
. 2. Sit up straight. Peak Flow Diary
3. Push the pointer on the peak flow meter to
base/zero. THESE INSTRUCTIONS ARE GUIDELINES,
REGARDLESS OF THE ADVICE IN THE PLAN, IF
4. Take a deep breath in. YOU ARE UNHAPPY ABOUT YOUR CONDITION
SEEK MEDICAL HELP.
5. Grip the mouthpiece with your teeth and seal
| A National Clinical Guideline
WHAT TO DO IN Relationship:
Education:
Inhaler Technique
Relievers & Controllers
Peak Flow Measuring / Recording
Asthma Self Management Plan
Allergic Triggers
Nasal Congestion / Medication
Exercise
Emergency Home Steroids
Smoking Cessation
Flu Vaccine (administered by)
Email: office@asthmasociety.ie
www.asthmasociety.ie
| Management of an Acute Asthma Attack in Adults
61
Project1_Layout 1 09/05/2011 06:46 Page 7
62
ASTHMA MANAGEMENT PLAN Date you started this Diary 8/11 9/11 10/11 12/11 Date Date
1. Have you had any asthma symptoms during the day (coughing, wheeze, tight chest or feeling breathless). 3
2. Has your asthma interfered with your usual activities (e.g. housework, climbing stairs, work or school, exercise). 3 3
E
3. Have you had difficulty sleeping because of your asthma symptoms (including coughing) 3
4. Have you needed to use your reliever inhaler more than twice a week
L
5. Have you had nasal symptoms (eg nasal congestion, sneezing, post nasal drip etc.)
Write down the total number of times
GREEN ZONE: ASTHMA UNDER CONTROL you took your treatment each day. Write down the total number of times you took your treatment each day. Write down the total number
Your Regular Treatment. Each day take:
P
Peak Flow 1. Reliever _______________________________________________________________________________________________________
n Daytime symptoms less than twice/week
between
n No limitation of exercise 80-100% 2. Controller _____________________________________________________________________________________________________ 3
M
n No waking at night due to symptoms of 3. ______________________________________________________________________________________________________________
3
Personal
n Reliever medication used less than twice per week
A
Best 4. ______________________________________________________________________________________________________________
n Peak flow between _________ and ___________ AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM
Before Exercise take _______________________________________________________________________________________________ 700 700 700
X
BLUE ZONE: ASTHMA GETTING WORSE
(aged 16 years and older)
E
n Daytime symptoms more than twice/week? Peak Flow
Step up your treatment as follows:
n Getting chesty cough? between
1. Increase your reliever to ________________________________________________________________________________________ 600 600 600
n Waking at night with cough or wheeze? 60-80%
2. Take __________________________________________________________________________________________________________
n New or increased daytime cough or wheeze? of
______________________________________________________________________________________________________________
n Symptoms after activity or exercise? Personal
______________________________________________________________________________________________________________
n Using reliever meds more than twice per week? Best
The need for repeated doses over more than 1 or 2 days signals the need for a review by your doctor.
n Peak flow between _________ and ___________ Use a spacer device if possible for maximum benefit.
E
500 500 500
n
n
Symptoms becoming more severe
Becoming breathless at rest
Peak Flow
between
Call your doctor/clinic: Phone No. _________________________ and get immediate advice.
Take the following medication.
1. Increase your reliever use to ____________________________________________________________________________________
P L 7
7
7
7
7
7
2. Additional Instructions _________________________________________________________________________________________ 7 7
n Chest tightness 40-60% 400 400 400
______________________________________________________________________________________________________________
| Management of an Acute Asthma Attack in Adults
ADULT MALE NORMAL VALUES Peak Expiratory Flow Rate – Normal Values
Peak Expiratory Flow Rate
For use with EU/EN13826 scale PEF meters only
Height 680
AGE in yrs
1.6m 5’3” 1.67m 5’6” 1.75m 5’9” 1.83m 6’ 1.90m 6’3”
660
15 485 498 511 524 535
20 540 555 571 586 398 640
25 575 591 608 624 637 620
30 594 611 628 645 659
600
35 601 618 636 653 666
40 599 615 633 650 664
| A National Clinical Guideline
580
45 590 606 623 640 653 560
50 575 591 608 624 637
55 557 572 588 603 616 540
Repeat doses should be given at 15-30 12 PUFFS VIA SPACER IS JUST AS EFFECTIVE AS NEBULISER UNLESS FEATURES
minute intervals or continuous nebulisation OF LIFE-THREATENING ASTHMA ATTACK
of salbutamol at 5-10mg/hour if inadequate
response to initial treatment
Bronchodilators/ 0.5mg 4-6 hourly mixed with nebulised β2
Ipratropium agonist in severe or life threatening asthma
or those with a poor initial response to β2
agonist therapy
Steroids/Prednisolone 40-50mg daily for 3 to 7 days or until Steroid tablets reduce mortality, relapses and hospital admissions. The
| Management of an Acute Asthma Attack in Adults
recovery earlier they are given in an attack the better the outcome.
Following recovery steroid tablets can be dropped abruptly and do not
need tapering provided that the patient is receiving inhaled steroids
(apart from those patients on maintenance steroid tablets or where
steroid tablets are needed for more than three weeks).
Steroids/Hydrocortisone IV (100mg, 6 hourly) ONLY USE IV IF COMATOSE OR VOMITING AS ORAL PREDNISOLONE IS JUST
AS EFFECTIVE
IV Magnesium Sulphate 1.2 – 2g IV infusion over 20 minutes but Consider giving single IV dose for patients with severe asthma who have
should only be used following consultation not had a good initial response to inhaled bronchodilator therapy or for
with senior medical staff life threatening or near fatal asthma attacks
IV Aminophylline Use only after consultation with senior
medical staff
Antibiotics Routine prescription of antibiotics is not indicated for asthma. Infection
often triggers an episode but is more likely to be viral rather than
bacterial in type
| A National Clinical Guideline
Appendix 3: Search Sources and Outputs
Appendix 3.1 Guideline clearing houses and organisations which develop guidelines and/or support evidence based practice; search
sources and outputs
Databases/ Search Terms Date searched Hits Screen for eligibility Screen for eligibility
organisation EXCLUDE INCLUDE
US National Guideline Advanced Search 10/04/2015 50 N=48 N=2
Clearinghouse Keyword: acute asthma
www.guideline.gov management Reasons for exclusion One is BTS/SIGN – INCLUDE
| A National Clinical Guideline
3 Duplicates
| Management of an Acute Asthma Attack in Adults
65
Databases/ Search Terms Date searched Hits Screen for eligibility Screen for eligibility 66
organisation EXCLUDE INCLUDE
Scottish Intercollegiate Adult acute asthma management 10/04/2015 68 N=67 N=1
Guidelines Network guidelines
(www.sign.ac.uk ) Reasons for exclusion BTS/SIGN
COPD/RTI http://www.sign.ac.uk/
Not systematic evidence guidelines/fulltext/101/index.
based clinical guideline html - Duplicate
National Institute for Search under GUIDANCE 10/04/2015 55 N=54 N=1
Health and Clinical Adult acute asthma management
Excellence UK (www. Reasons for exclusion Quality Standard on Asthma
(aged 16 years and older)
management of asthma
Outputs Hits First screen - Excluded 426 First screen - include as
441 potentially eligible 15
Second screen
Exclude 11
Include 4 (BTS/SIGN;
GINA; CTS; AUSTRALIAN
HANDBOOK)
| Management of an Acute Asthma Attack in Adults
67
Appendix 3.2. International asthma, thoracic and lung associations.
68
Organisations Search Term Date Hits Screen for eligibility Screen for eligibility
of search EXCLUDE INCLUDE
Asthma Societies/
Associations
Asthma UK http://www. Guidelines 11/4/15 58 N=55 N=3
asthma.org.uk/Default.aspx
Reasons for exclusion: BTS/SIGN (2014 guidelines -
Emergency asthma care INCLUDE)
(aged 16 years and older)
British Lung Foundation (BLF) Adult acute asthma guidelines 11/4/15 32 N=31 N=1
www.blf.org.uk Reasons for exclusion: NICE
SIGN guideline from 2008 (Asthma Standard ONLY) -
Exclude
Asthma Society of Ireland “guidelines” 11/4/15 9 N= 9 N=0
(ASI) Reasons for exclusion:
www.asthma.ie Information for patients/
families;
Mentions GINA guidelines
| A National Clinical Guideline
Organisations Search Term Date Hits Screen for eligibility Screen for eligibility
of search EXCLUDE INCLUDE
American Academy “asthma guidelines” 11/4/15 38 N=38 N=0
of Allergy Asthma and Reasons for exclusion: Education needs and practice
Immunology (AAAI) NIH 2007 guidelines gaps recognised-
https://www.aaaai.org/ NHLBI guidelines (2007) Asthma Management: a topic
home.aspx identified at the AAAI members
meeting on the 8/10/2014
Asthma and Allergy Asthma Management 11/4/15 51 N=51 N=0
Foundation of America Reasons for exclusion:
| A National Clinical Guideline
Duplicate
Asthma Society of Canada “asthma management” 12/4/15 34 N=33 N=1
(ASC) Reasons for exclusion:
www.asthma.ca Asthma videos; asthma action GINA guidelines (2014) – there
plans; news releases; health is 2015 version available
index; asthma control guide;
COPD guidelines using CTS
guidelines
Allergy and Asthma Advanced Search: 12/4/15 2 N=2 Click: Information about
| Management of an Acute Asthma Attack in Adults
- Exclude
Asthma New Zealand Asthma Management 11/4/15 9 N=9 N=0
www.asthma-nz.org.nz Reasons for exclusion:
Adult asthma management
plan; COPD management;
Asthma Management Nursing
Course
The Asthma Foundation Adult acute asthma guidelines 11/4/15 1 N=1 Recommended:
www.asthmafoundation.org. Reasons for exclusion: • BTS/SIGN
nz “seeking support to update • GINA guidelines
guidelines” (until website has the updated
2002 guidelines only guidelines in place)
Asthma Australia Click: Health Professionals 11/4/15 1 N=0 N=1
www.asthmaustralia.org.au Click: Health Professionals GINA Guidelines (2014)
Resources
National Asthma Council Adult Acute Asthma Guidelines 11/4/15 114 N=113 N=1
(aged 16 years and older)
NAEPP 1997;
Journals not guidelines (GINA
guidelines mentioned);
2011 WAO White Book on
Allergies
(2004/2005);
Tobacco Control Guideline
International Primary Care Adult Acute Asthma Guidelines 12/4/15 58 N=58 N=0
Respiratory Group (IPCRG) All journal publications
www.theipcrg.org however; GINA/NICE/BTS
mentioned in same
BTS/SIGN mentioned for
children guidelines
Global Allergy and Asthma No Search Box 12/4/15 2 N= 0 N=2
Patient Platform(GAAPP) Click: Links • GINA 2014
www.ga2p2.org Click: Guideline Organizations • ARIA 2008 (OUT OF DATE)
www.irishthoracicsociety.
com
Scottish Thoracic Society Adult acute asthma guidelines 11/4/15 5 N=5 N=0
(STS) Reasons for exclusion:
www.sts.rcpe.ac.uk No guidelines
However, ATS/BLF/BTS/
ERS all mentioned
The Thoracic Society of Adult acute asthma guidelines 11/4/15 69 N=69 N=0
Australia and New Zealand 2006 guidelines only
| Management of an Acute Asthma Attack in Adults
Second Screen
Exclude 29
Include 3
(SIGN/BTS; GINA; AUSTRALIAN
HANDBOOK)
| A National Clinical Guideline
Appendix 3.3 Grey literature databases
Grey Literature Search Terms Dates Hits Screen for eligibility Screen for eligibility
Databases EXCLUDE INCLUDE
Agency for Healthcare Advanced Search 10/04/2015 N=261 N=261 N=0
Research and Quality With all the words:
http://www.ahrq.gov/ adult acute asthma Reasons for exclusion –
management same
With the exact phrase:
"guideline" Quality improvement
| A National Clinical Guideline
Second Screen
Exclude 6
[but waiting for Japanese –
authors response]
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 79
EXCLUDE
Australian Asthma Handbook 2014 National Asthma Australia Updated TBC – site states search INCLUDE??
(aged 16 years and older)
Council Australia English April 2015 information to follow Association emailed to try
http://www.asthmahandbook.org. (minor get pdf version…..
au/ update
to version Follow up – missing data;
March 2014) plus also limited data on
‘acute’ asthma
First
Published EXCLUDE
1990
Clinical Guideline for the Diagnosis, New York State Dept. Updated Not a national guideline
| Management of an Acute Asthma Attack in Adults
EXCLUDE
Consensus Statement for the Canadian Thoracic Canada, Updated June 2010 (for This is a published paper
diagnosis and management of Society English 2012 literature) on the update of 4 key
asthma questions; literature search
First Oct 2010 (for ended 2010
(Lougheed MD, Lemiere C, published systematic reviews) INCLUDE?
Ducharme FM, Licskai C, Dell 2010 Following discussion with
SD, Rowe BH, itzgerald M, Leigh GDG – this more focused on
R, Watson W, Louis-Philippe B, chronic asthma not ‘acute’
Canadian Thoracic Society Asthma
Clinical Assembly. Can Respir J. EXCLUDE
2012. 19(2):127-164)
| A National Clinical Guideline
Title/Reference Publisher Country, Publication End of search date Comments
language date
Diagnosis and Management of ICSI Bloomington, Updated Nov 2011 (for Not a national guideline
Asthma Institute for Clinical Minnesota 2012 systematic reviews)
Systems Improvement English EXCLUDE
(Sveum R, Bergstrom J, Brottman First March 2012 (for patient
G, Hanson M, Heiman M, Johns published education and self-
K, Malkiewicz J, Manney S, Moyer 1994 management)
L, Myers C, Myers N, O’Brien M,
Rethwill M, Schaefer K, Uden
D. Institute for Clinical Systems
| A National Clinical Guideline
EXCLUDE
Guideline for the management of South African South Africa Updated These guidelines are based
acute asthma in adults Thoracic Society English 2013 on GINA
aspx?id=38693
International ERS/ATS guidelines on ERS/ATS International Published Not acute asthma
definition, evaluation and treatment European Respiratory English 2014 (confirmed with P Manning)
of severe asthma Society/American
Thoracic Society EXCLUDE
(Chung et al. 2014 Eur Respir J
43:343-373)
Japanese Guideline for Adult Japanese Society of Japan Updated Limited information on
Asthma 2014 Allergology English 2014 methodology in terms of
| Management of an Acute Asthma Attack in Adults
EXCLUDE
Quality Standard for Asthma NICE National UK, English Last Is this a standard as opposed
Institute for Health modified to a guideline?
and Care Excellence Feb 2013 Also standards seem to be
informed/underpinned by
BTS/SIGN asthma guideline
EXCLUDE
| A National Clinical Guideline
Title/Reference Publisher Country, Publication End of search date Comments
language date
Saudi Initiative for asthma – 2012 Saudi Initiative for Saudi, Updated The paper states that This guideline is based on
update: guidelines for the diagnosis Asthma (SINA) English 2012 the updated guidelines other guidelines – GINA and
and management of asthma in followed the same NAEPP
adults and children methodology as the
original guidelines EXCLUDE
(Al-Moamary et al. 2012. Annals of
Thoracic Medicine. 7(4):175-204)
SIGN 141. British guideline on the SIGN/BTA Britain, English Updated Searches conducted
| A National Clinical Guideline
1. The overall objective(s) of the guideline is (are) specifically described.
1
7
2
3
4
5
6
Strongly
Disagree
Strongly
Agree
Comments
2. The health question(s) covered by the guideline
is (are) specifically described.
1
7
2
3
4
5
6
Strongly
Disagree
Strongly
Agree
Comments
3. The population (patients, public, etc.) to whom
the guideline is meant to apply is
specifically described.
1
7
2
3
4
5
6
Strongly
Disagree
Strongly
Agree
Comments
DOMAIN 2. STAKEHOLDER INVOLVEMENT
2
individuals from all relevant professional
4. The guideline development group includes
groups.and preferences have been sought.
views
1
7
2
3
4
5
6
Strongly
Disagree
Strongly
Agree
Comments
5. The views and preferences of the target population (patients, public, etc.) have been
sought.
1
7
2
3
4
5
6
Strongly
Disagree
Strongly
Agree
Comments
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 85
* Drawing
on
the
AGREE
II
training
tools
it
is
suggested
that
at
minimum
2-‐2.5
hours
should
be
factored
in
to
complete
the
entire
appraisal
of
the
SIGN/BTA
guideline.
* It
is
important
to
factor
in
time
for
the
following
elements;
* Reading
the
entire
SIGN/BTA
guideline
document
* Participation
in
online
training
(details
to
follow
on
next
slide)
* Reading
of
the
AGREE
II
Manual
* Completion
of
the
guideline
document
appraisal
* Note:
some
of
these
tasks
may
be
conducted
concurrently
such
as
participating
in
online
training
and
reading
the
manual;
and
the
appraisal
could
be
done
in
steps
according
to
the
domains
of
the
AGREE
II
Instrument
if
time
needed
to
be
broken
up
* Note:
This
time
will
also
need
to
be
factored
in
for
appraising
the
other
3
guidelines
in
week
3
(22nd-‐29th
April);
the
time
per
evaluating
each
document
might
be
slightly
less
due
to
familiarity
with
the
appraisal
tool/process
following
the
training
appraisal
e.g.
1-‐1.5
hours
per
each
guideline
(i.e.
3-‐4.5
hours
for
the
final
3
guideline
documents)
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 87
Score Meaning
* Example
of
q User’s
Manual
Description
q Where
to
Look
q How
to
Rate
* For
item
1
Domain
1
(scope
and
purpose)
* (p.15
AGREE
II
User’s
Manual)
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 91
Scope
and
100
purpose
Stakeholder
80
involvment
Rigour
of
60
development
40
Clariy
of
presentaFon
20
Applicability
0
Editorial
BTS/SIGN
GINA
independence
Overall
Guideline
Guideline
assessment
100
90
80
70
60
50
40
30
BTS/SIGN
20
10
Guideline
0
GINA
Guideline
re pm t
1
o ve me
pe bi
en
OA
l
in pp aC
ity e ve e
de lica on
nd lity
ria A ent ent
ce
f
p lo n
ar f
d ol os
Cl r
o
inv urp
p
go er d
s
Ri old
an
eh pe
ak Sco
ito
Ed
St
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 93
BTS/SIGN Guideline
7
6
5
4
3
Item
1
2
Item
2
1
Item
3
0
r
1
r 2
r 3
r
4
se
se
se
se
ai
ai
ai
ai
pr
pr
pr
pr
Ap
Ap
Ap
Ap
7
6
5
4
3
Item
4
2
Item
5
1
Item
6
0
r
1
r 2
r 3
r
4
se
se
se
se
ai
ai
ai
ai
pr
pr
pr
pr
Ap
Ap
Ap
Ap
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
94 (aged 16 years and older)
7
6
Item
7
5
Item
8
4
Item
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(aged 16 years and older) 113
A At least one meta- 1++ High quality RCTs and Evidence is from endpoints
analysis, systematic meta-analyses, meta-analyses. of well-designed RCTs or
Note: In BTS/SIGN review, or RCT rated systematic reviews Rich body of meta-analyses that provide a
this is referred to as as 1++, and directly of RCTs, or RCTs with evidence. consistent pattern of findings
GRADE A whereas in applicable to the a very low risk of in the population for which
GINA this is referred target population; or bias the recommendation is
to as EVIDENCE A A body of evidence made. Category A requires
consisting principally 1+ Well conducted substantial numbers of studies
of studies rated as 1+, meta-analyses, involving substantial numbers
directly applicable systematic reviews, of participants.
to the target or RCTs with a low
population, and risk of bias
demonstrating
overall consistency of 1 - Meta-analyses,
results systematic reviews,
or RCTs with a high
risk of bias
B A body of evidence 2++ High quality RCTs and meta- Evidence is from endpoints
including studies systematic reviews analyses. Limited of intervention studies that
Note: In BTS/SIGN rated as 2++, directly of case control or body of data. include only a limited number
this is referred to as applicable to the cohort studies of patients, post hoc or
GRADE B whereas in target population, High quality case subgroup analysis of RCTs or
GINA this is referred and demonstrating control or cohort meta-analysis of such RCTs. In
to as EVIDENCE B overall consistency of studies with a general, Category B pertains
results; or very low risk of when few randomised trials
Extrapolated confounding or exist, they are small in size,
evidence from bias and a high they were undertaken in a
studies rated as 1++ probability that the population that differs from
or 1+ relationship is the target population of
causal the recommendation, or
the results are somewhat
inconsistent.
Risk Factor: Any patient with >= risk factor for exacerbations
(including poor symptom control)
Treatment Strategy:
• Ensure patient is prescribed regular ICS-containing
controller (Evidence A)
• Ensure patient has a written action plan appropriate for
their health literacy (Evidence A)
• Review patient more frequently than low risk patients
(Evidence A)
• Check inhaler technique and adherence frequently
(Evidence A)
• Identify any modifiable risk factors (Evidence D)
Risk Factor: >=1 severe exacerbation in last year
Treatment Strategy:
• consider alternative controller regimes to reduce
exacerbation risk e.g. ICS/formoterol maintenance and
(aged 16 years and older)
Treatment Strategy:
• encourage smoking cessation by patient family; provide
advice and resources (Evidence A)
• consider higher dose of ICS if asthma poorly-controlled
(Evidence B)
Risk Factor: Low FEV1 especially if <60% predicted
Treatment Strategy:
(aged 16 years and older)
Treatment Strategy:
• Strategies for weight reduction (Evidence B)
• Distinguish asthma symptoms from symptoms due to
| Management of an Acute Asthma Attack in Adults
Treatment Strategy:
• arrange mental health assessment (Evidence D)
• help patient to distinguish between symptoms of anxiety
and asthma; provide advice about management of
panic attacks (Evidence D)
Risk Factor: Major socioeconomic problems
Treatment Strategy:
• Identify most cost-effective ICS based regimen (Evidence
D)
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
Risk Factor: Confirmed food allergy
Treatment Strategy:
• Appropriate food avoidance; injectable epinephrine
(Evidence A)
Risk Factor: Allergen exposure if sensitized
Treatment Strategy:
• Consider trial of simple avoidance strategies; consider
| A National Clinical Guideline
cost (Evidence C)
• Consider step up of controller treatment (Evidence D)
• The efficacy of allergen immunotherapy in asthma is
limited (Evidence A)
Risk Factor: Sputum eosinophilia (limited centres)
Treatment Strategy:
• Increase ICS dose independent of level of symptom
control (Evidence A)
Specialist Settings/
Populations
(aged 16 years and older)
| Management of an Acute Asthma Attack in Adults
121
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 122
Acute asthma Give drug therapy for acute asthma as for non-pregnant ICS prevent exacerbations of asthma during pregnancy
management in patients including systemic steroids and magnesium (Evidence A) and cessation of ICS during pregnancy is a
pregnancy sulphate (Grade C) significant risk factor for exacerbations (Evidence A)
Deliver high flow oxygen immediately to maintain On balance given the evidence in pregnancy for adverse
saturation 94–98% (Grade D) outcomes from exacerbations (Evidence A) and for safety
of usual doses of ICS and LABA (Evidence A) a low priority
Acute severe asthma in pregnancy is an emergency and should be placed on stepping down treatment (however
should be treated vigorously in hospital (Grade D) guided) until after delivery (Evidence D)
(aged 16 years and older)
Systemic corticosteroids
OCS should be given promptly especially if the patient is
deteriorating or had already increased their reliever and
(aged 16 years and older)
Systemic corticosteroids
Systemic corticosteroids speed resolution of exacerbations
and prevent relapse and should be utilized in all but the
mildest exacerbations in adults (Evidence A).
Inhaled corticosteroids
Within the emergency department: high dose ICS given
within the first hour after presentation reduces the need
for hospitalization in patients not receiving systemic
corticosteroids (Evidence A). When given in addition to
systemic corticosteroids evidence is conflicting (Evidence
B).
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
On discharge home: the majority of patients should
be prescribed regular ongoing ICS treatment since the
occurrence of a severe exacerbation is a risk factor for
future exacerbations (Evidence B).
Other treatments:
Magnesium
Intravenous magnesium sulfate is not recommended
for routine use in asthma exacerbations; however when
administered as a 2g infusion over 20 minutes it reduces
hospital admissions in some patients including adults with
FEV1 <25-30% predicted at presentation (Evidence A).
Non-invasive ventilation
If NIV is tried the patient should be monitored closely
(Evidence D). It should not be attempted in agitated
patients and patients should not be sedated in order to
receive NIV (Evidence D).
| Management of an Acute Asthma Attack in Adults
125
Context/Category BTS/SIGN - Recommendations GINA - Recommendations 126
Follow up after After emergency department presentation comprehensive
emergency department intervention programs that include optimal controller
presentation or management inhaler technique and elements of self-
hospitalization management education (self-monitoring, written action
plan and regular review) are cost effective and have
shown significant improvement in asthma outcomes
(Evidence B).
Self-Management
Supporting self- A hospital admission represents a window of opportunity
(aged 16 years and older)
ICS/formoterol
as needed (max
formoterol total
72mcg/day)
Maintenance At least double ICS; B
ICS with SABA as consider increasing
reliever ICS to high dose
(maximum 2000
mcg/day BDP
equivalent)
Maintenance ICS/ Quadruple B
formoterol with maintenance
SABA as reliever ICS/formoterol
(maximum
formoterol
72 mcg/day
| A National Clinical Guideline
Context/Category BTS/SIGN - Recommendations GINA - Recommendations
Add oral
| A National Clinical Guideline
corticosteroids
(OCS) and contact
doctor:
OCS (prednisone or Add OCS for severe A
prednisolone) exacerbations
(E.g. PEF or FEV1
<60% personal
best or predicted)
or patient not
responding to
treatment over 48
hours
Adults: D
prednisolone 1mg/
kg/day (maximum
50 mg) usually for
5-7 days.
Tapering is not B
(aged 16 years and older)
Oral corticosteroids
For most patients the written asthma action plan should
provide instructions for when and how to commence OCS.
Typically a short course of OCS is used (e.g. 40-50 mg/day
usually for 5-7 days, (Evidence B) for patients who:
Keywords used Y Y
Combinations of keywords Y Y
A hand search of the reference lists was completed N p.19 SIGN 50 U Not reported
Local experts and/or societies were asked for guideline recommendations U Not specific U Not specific
to asking for to asking for
recommendations recommendations
| A National Clinical Guideline
Guideline 1: BTS/SIGN Guideline 2: GINA
Yes Unsure No Comment Yes Unsure No Comment
Overall was bias in the selection of articles avoided? U U
Inclusion and exclusion criteria reported U Not explicit U Not explicit
The number of persons who selected and analysed the data is Y Number of Y p.vi 2 members
documented people who evaluate and ans.
analysed was Q’s on scientific
2; selection not impact
reported
The procedure to solve disagreement is described Y SIGN 50 Y Consensus/Voting
| A National Clinical Guideline
@ meetings
The number of references analysed is documented N N
The number of excluded references is documented N N
The reasons for excluding references are given N N
The criteria for inclusion and exclusion are clinically & methodologically U I & E criteria not U I & E criteria not
valid explicit explicit
The reasons for exclusion conform to the selection and exclusion criteria U Not reported U Not reported
The process for selection of evidence is adequately described N N
Comment Followed SIGN 50; actual Comments The actual process from
process from searching evidence to searching the evidence to extracting data
extracting data in evidence tables not in the evidence tables was not reported;
reported; no PRISMA diagram no PRISMA diagram
(aged 16 years and older)
| Management of an Acute Asthma Attack in Adults
133
Appendix 14: Tool 14: Evaluation sheet – scientific validity of guidelines 134
Health Question – “Acute asthma management in adults” Guidelines 1: BTS/SIGN Guideline 2: GINA
Given the search strategy, the risk that relevant evidence has been missed is low Y U Complete
search
strategy not
(aged 16 years and older)
explicit
Settings and protocols of selected studies fit with the health question Y Yes and if Y
different
reported
The criteria used for assessing the quality and validity of the selected studies are Y Y
| Management of an Acute Asthma Attack in Adults
The risk that biased evidence has been reported is low Y Evidence clearly Y Evidence
presented clearly
presented
When a meta-analysis was performed, statistical analyses were appropriate. N/A N/A
Sensitivity analysis and test of heterogeneity was performed
| A National Clinical Guideline
Health question – “Acute asthma management in adults” Guideline 1: SIGN/BTA Guideline 2: GINA
The evidence was direct. Patients and interventions included in the studies were Y Y
comparable to those targeted by the recommendations
Conclusions were supported by data and/or the analysis; results were consistent Y Y
from study to study. When inconsistencies existed in data, considered judgement
was applied and reported.
The conclusions are clinically relevant. (Statistical significance is not always equal Y Y
| A National Clinical Guideline
to clinical significance)
Overall, the scientific quality of the recommendations do not present risks of bias Y Y
Comments Comments
(aged 16 years and older)
| Management of an Acute Asthma Attack in Adults
135
Appendix 15: Tool 15: Evaluation sheet – Acceptability/Applicability 136
Health Question – Acute asthma management in adults Guidelines 1: SIGN/BTA Guideline 2: GINA
The recommendations are compatible with the culture and values in the Y Y
setting where it is to be used
There are no constraints, legislation, policies, or resources in the health Y There might be Y
care setting of use that would impede the implementation of the some implications
| Management of an Acute Asthma Attack in Adults
Comments Comments
| A National Clinical Guideline
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 137
Key message
This review of the literature on the economic evaluation of the acute asthma management in adults and
the budget impact analysis supports the clinical guideline recommendations.
The report was completed by Prof. Patrick Manning, Consultant Respiratory Physician and
Clinical Lead for National Clinical Programme for Asthma (NCPA), Noreen Curtin (Programme
Manager NCPA 2012-2013) and Michelle O’Neill, Senior Health Economist, Health Technology
Assessment Directorate, Health Information and Quality Authority in collaboration with Prof
Stephen Lane, Chair (Clinical Advisory Committee-NCAP), Dr. Ina Kelly, Specialist in Public
Health Medicine (NCAP), Dr Kathleen Mac Lellan, Director of Clinical Effectiveness, CMO Office,
Department of Health and Mr. Gethin White, Clinical Librarian, Health Service Executive (HSE)
library services.
Background
The overarching aim of the National Clinical Programme for Asthma (NCPA) is to reduce the
morbidity and mortality associated with asthma in Ireland and to improve clinical outcomes and
the quality of life for all patients with asthma. A key component is improved management of
people with asthma in primary care and thereby avoiding emergency asthma attendance at
GP out of hours services (GPOOH – estimated 21,800 adult visits annually) and at hospital ED and
in-patient admission services. There is a good scientific rational for this approach and this work
has been shown to be effective at international levels with significantly improved outcomes
focusing on improving asthma control in the community and thereby reducing asthma morbidity
and mortality overall. This includes reduced adult acute asthma attendances at Emergency
Departments (currently estimated at about 12,000 adult visits annually), in-patient admissions
in hospital (currently about 1,460 adult admissions annually) and accounting for 5,825 acute
bed days used, of which 70 patients had an ICU admission utilising 222 ICU bed days. (Hospital
In-patient Enquiry - HIPE 2011) Patients with acute asthma exacerbations are at an increased
risk of death (currently about 1 per week (most asthma deaths occur in adults)) and 90% of
deaths from asthma are preventable. Acute attendances and admissions may have their roots
in prior inadequate care in the community and in a lack of patient involvement in controlling
symptoms through guided self-management. Poorly controlled asthma is costly; the efforts in
the community at primary and specialist care levels should be firmly focused on achieving and
maintaining good control in as many patients as possible. As much as a third of the overall cost
of managing asthma may be related to emergency attendances, hospitalisation and death,
with hospitalisation accounting for between 20 and 25% of the overall cost (5). The Asthma
Society of Ireland has estimated the cost of asthma care in the Republic Of Ireland is of the
order of €6.5 million and due largely to uncontrolled asthma. Much of this cost relates to adult
admissions and the estimated cost in 2005 as identified in an international study to determine the
Cost Of Asthma exacerbations (20) was €3,809 per patient per admission but this is equivalent to
€4,733 in 2013. (CSO/CPI for health).
International research has identified that the majority of hospital admissions for asthma are
emergency admissions, of which 70% may have been preventable with appropriate early
intervention (21, 22) Many people with asthma have poor control of their condition and in a
a See Appendix 5.4 list of References for Economic Evaluation Literature Review where ‘Reference’ is indentified in text
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
140 (aged 16 years and older)
large scale survey in the UK reported that around 35% of adults with asthma had had an asthma
attack in the previous 12 months (The Health Survey for England found that 30-40% of people
with asthma had had an asthma attack in the previous 12 months)(23). Poorly controlled
asthma is more expensive than well controlled asthma for the NHS. The annual cost of an NHS
patient who has an exacerbation of asthma requiring hospital treatment is likely to be 3.5 times
that of a patient who does not. It is expected that it is similar in the Republic of Ireland. Thus,
there is significant scope for reducing overall community costs for asthma by improving disease
control through implementing a programme of guideline based chronic disease management
at primary care level linked when necessary to specialist care for all patients with asthma and
appropriate management of exacerbations as outlined in these acute guidelines for adult
asthma. This is what is envisaged in the National Model of Care for Asthma.
The implementation of the MOCA will ensure that patients with asthma will benefit from being
part of a well-managed integrated system of care, coordinated at primary care level and
financed to support seamlessness and patient-centeredness.
The team at primary care level will deliver ongoing high quality health care for patients with
asthma with 24/7 access to care. This team will be led by an experienced general practitioner
(GP) with knowledge and training in asthma care, with a trained practice nurse that will educate,
support and enable patients to effectively manage their asthma. The community pharmacist
will assist the GP in asthma management by communicating concerns about patient’s control
and providing patient education on inhaler technique and peak flow monitoring. They will
also advise patients on asthma drug therapies and potential drug interactions (medicine use
review). GPs will refer patients to the specialist service in secondary care who will assist the GP to
manage ‘difficult to control’ asthma in the community and be responsible for monitoring acute
asthma care in ED and acute medical unit (AMU)/ acute medical assessment unit (AMAU).
If necessary, people with asthma will be admitted for acute management and stabilisation
in accordance with best practice guidelines. International evidence demonstrates that
implementing a national asthma management programme over a number of years can reduce
asthma hospitalisations by 50%, cost per patient by 30%, and deaths from asthma by 90% (24).
problems with asthma care and management and will include some or all of the following with
the patient and/or caregiver:
• Inhaler technique
• Adherence to and understanding of asthma medications
• Self-management education including personal asthma plans and self-monitoring
• Management of co-morbidities and triggers including allergic rhinitis
• Smoking cessation and/or avoidance or exposure to second hand smoke
This guideline provides clear guidance for the assessment and treatment of acute asthma in
general practice, by paramedic services, the Emergency Department and in the acute hospital
for adults. The guideline articulates clear criteria for when patients with acute asthma should be
admitted and discharged. The guidelines also mention that if clinical staff fail to assess severity of
an acute exacerbation by an objective measurement and under-use corticosteroids it can lead
to poor outcomes including avoidable deaths and thus education is required around guideline
managed care.
This guideline for adults (along with the NCPA’s acute asthma guideline for paediatrics (26))
is a significant management tool, based on current international best practice and will assist
in appropriate management and follow up of acute exacerbations of asthma. Patients with
an acute exacerbation of asthma are at increased risk of death and readmission for asthma if
not managed appropriately. Patients who attend GPOOH, ED and those who are admitted to
hospital for acute asthma should be followed up by attending their GP within 2 working days
of discharge for ongoing asthma management. International best practice recommends that
all patients admitted to hospital should be followed up on discharge from hospital in a medical
specialist clinic for 1 year (in conjunction with their GP) until stable.
• Hospital staff, including ED and in-patient hospital personnel involved in triage, assessment
and management of acute asthma should have the appropriate knowledge and training
in acute asthma assessment and ongoing care for this condition.
• There is over-use of nebulisers in acute situations. Delivery of short acting bronchodilators
by nebuliser instead of by standard inhaler with a spacer can encourage a reliance on
hospital care, and lead to repeat hospital attendances by patients, when delivery using an
inhaler and spacer may be adequate. This guideline recommends that Hospital Emergency
Departments, GPOOH and urgent care centres do not use nebulisers routinely for treatment
of acute attacks, except where appropriate.
• Patients who are admitted to hospital should be managed in a ward where staff, including
nurses, have adequate training and experience in monitoring acutely ill asthma patients
and are proficient at administering appropriate medications for this.
• Every acute hospital admissions unit should have a senior clinical individual who is responsible
for ensuring that asthma care across all departments conforms to the Irish Acute Asthma
Attack in Adults Guideline, and to ensure that records and audit processes and outcomes
are identified and stored.
• Implementation of bundles of care for acute asthma care to encourage adherence to best
practice guidelines is recommended locally.
Denmark, Ireland, Latvia, Norway, Poland, Russia, Slovakia, Slovenia and Spain. Multiple
regression analysis of the 2,052 exacerbations included in the economic analysis showed that
the cost of exacerbations was significantly affected by country (P<0.0001). Mean costs were
significantly higher in secondary care (€1349) than primary care €445 (P=0.0003). Age was a
significant variable (P=0.0002), though the effect showed an interaction with care type i.e. older
adults needing hospital care had increased costs compared to younger adults (P<0.0001). As
severity of exacerbation increased, so did secondary care costs, though primary care costs
remained essentially constant. In conclusion, the study showed that asthma exacerbations
are costly to manage, suggesting that therapies able to increase asthma control and reduce
the frequency or severity of exacerbations may bring economic benefits, as well as improved
quality of life.
In addition, international studies (references 62-66) have identified that asthma exacerbations
leading to emergency management and in-patient hospitalisations can be costly through both
direct and indirect costs. Direct costs include emergency care, hospital admissions, associated
tests and management and the cost varies depending on the asthma exacerbation severity.
In a study of 401 asthma patients in northern California USA (published in 2003, data from 1998),
the annual average cost of adult hospital admissions was €564 accounting for 15% of costs, In
Canada (published in 2013, data in abstract form from 2011), the average hospitalisation costs
per acute asthma episode ranged from €306 to €617 and the average costs for ED visit per
acute asthma episode ranged from €146 to €184, excluding medication cost. The analysis of
the cost of asthma in Spain (which included emergency care, hospital admissions, and tests)
showed that the average annual cost of asthma in adults in Spain (published in 2009, data from
2007) comes to €2,275 per patient, considering both direct and indirect costs. The average
annual cost per patient to the Spanish National Health Service is €2,021. In both Korea (2012)
and the USA (2012), the burden of asthma was higher for patients with poorly controlled asthma
and in USA, asthma patients (12-64 years) with exacerbations vs those without exacerbations
had significantly higher asthma-related costs [$1740 vs $847, (€1450 vs €700) P<0.0001]. Sixty-eight
international studies reviewed between 1966-2008 found that hospitalisation and medications to
be the most important cost driver of direct costs. Recommendations from this review included
strategies for including education of patients and physicians in asthma assessment and care,
and regular follow-up being required to reduce this economic burden of asthma.
programme was run by the Finnish Lung Health Association (Filha)b, and employed one
pulmonologist. Overall, the direct extra cost of the programme was €0.65 million including
€125,000 from the Finnish Ministry of Social Affairs and Health who gave their political
commitment to the programme. The intervention was managed by integrating the tasks into the
everyday practice of healthcare staff. The conclusion of the project was that it is possible to
reduce the morbidity of asthma and its impact on individuals as well as on society through a co-
ordinated programme including health professional Education on asthma exacerbations. A
similar programme is outlined in detail in the Irish National Clinical Programme for Asthma‘s
Model of Care.
[Asthma statistics in Finland for the period 1981–1996 showing a relative increase in the number
of patients entitled to special reimbursement for their drug costs and decreases in the death
rate and days in hospital for these patients (index, 1981 = 100)].
Asthma education for emergency department staff can also be effective in improving asthma
care. In a study from Kuwait (67) a new policy was implemented in a single acute hospital
emergency department (which is planned in Ireland outlined in the National Model of Care
for Asthma). This policy was aimed at reducing medical admissions to overcome the problems
of a shortage of inpatient beds, overcrowding, rising costs and exhausted resources. A key
component was the implementation of disease management guidelines for a number of
medical conditions including acute asthma and was prospectively studied over a period of 3
years from introduction of the policy and compared with the 3-year period before the policy
was instituted. The outcome was a significant reduction in admission rates after introduction of
the new policy with a relative reduction of 49.2% for bronchial asthma.
Internationally hospitalisation and medications were found to be the most important cost
driver of direct costs. In an international review of 68 studies between 1966-2008, (68)
recommendations were identified which included strategies for including education of patients
and physicians in asthma assessment and care, and regular patient follow-up by educated
healthcare professionals being required to reduce the economic burden of asthma.
About 20% or more of adult asthma patients may develop a repeat exacerbation requiring
ED attendances and/or early re-admission to hospital within 1 month of discharge (73, 74).
Much of this relates to suboptimal discharge management following the initial admission and
thus is creating a potentially avoidable burden for patients and medical services. Involvement
and follow up in an asthma nurse / respiratory specialist clinic has been shown to reduce re-
hospitalisation rates to 0% with asthma nurse specialist input (75). If admitted to hospital for
acute asthma it is recommended that patients be followed up in a specialist medical outpatient
department (OPD) for 1 year until stable (adult asthma patients following an acute exacerbation
may not followed up in the medical OPD on discharge). Occasionally patients may be followed
in specialist medical OPD indefinitely if they have more severe or difficult to control asthma.
D. MDI reliever with spacer device for acute asthma compared to wet nebulisations
(References 76-77)
Cates et al. evaluated the use of the reliever therapy for acute asthma as MDU or wet
nebulisation and searched the Cochrane Airways Group Trial Register and reference lists of
articles (76). This search included a total of 1,897 children and 729 adults in 39 randomised
control trials. Thirty-three trials were conducted in the emergency room and equivalent
community settings, and six trials were on in-patients with acute asthma (207 children and 28
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
146 (aged 16 years and older)
adults). Nebuliser delivery produced outcomes that were similar to metered-dose inhalers
delivered by spacer in adults. Method of delivery of inhaled β2 agonists reliever medication did
not appear to affect hospital admission rates. The MDI/spacer can also be cheaper and thus
may be a more economical alternative to wet nebuliser delivery. Dhuperet al. (77) reported
that demonstration of equivalent efficacy of β2 agonist delivery using a metered dose inhaler
(MDI) with a spacer device compared to using a wet nebuliser in asthma patients. However,
the median cost of treatment per patient was $10.11 (SD $10.03-$10.28) vs. $18.26 (SD $9.88-
$22.45) in the spacer and nebuliser groups, respectively (p < 0.001). They concluded that
there is no evidence of superiority of nebuliser to MDI/spacer β2 agonist delivery for emergency
management of acute asthma in this inner-city adult population. Thus the MDI/spacer may be
a more economical alternative to wet nebuliser delivery in patients other than those with severe
exacerbations. This evidence supports Recommendation 11 of the Management of an Acute
Asthma Attack in Adults Guideline.
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(aged 16 years and older) 147
1. Staff training
The main costs for guideline implementation is the costs associated with structured training
for clinical staff in hospital and GPOOH settings on acute asthma guideline managed care.
It is critical that medical staff involved with acute asthma patients have the knowledge and
training to manage these patients appropriately.
Nurses: Hospital and practice nurses in primary care (PNs) and Out of Hours (OOH) Nurses
The National Asthma Programme and the Asthma Society of Ireland (ASI) have developed an
online asthma education programme which is aimed at the healthcare professional. The course
contains two components, 6 x 30 minute e-learning modules based on GINA guidelines (these
should be completed within 6 months of commencement) and an additional practical workshop
(½ day session – 3 hr). This workshop is delivered by Respiratory Clinical Nurse Specialists. The HSE
have employed a service level agreement (SLA) with ASI to cover the cost of this e-learning
package so there is no direct cost to the person undertaking the training. The SLA cost €29,084
per year from 2011 – 2014 with a total cost of €116,336. This SLA will continue in 2015. However,
the SLA with ASI includes time for work on the educational programme along with other aspects
(patient information, development of chronic asthma guidelines, national MOC etc.) thus it is
not possible to apportion costs to acute asthma guidelines time.
The e-learning training is mandatory for Practice Nurses (PNs) and is optional for nurses/staff
working in secondary care. However, all nurses should undertake the ½ day workshop on asthma
practical skills (asthma management plans, medications, guidelines implementation and follow
up, peak flow readings and inhaler technique).
To cost the staff time for education, an average salary at staff nurse grade (HSE, 2013) was
assumed for those attending. This includes staff time attending training and clinical nurse
specialist (CNS) time delivering training.
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148 (aged 16 years and older)
This is envisaged as a once off training cost so that after initial training the onus is on the individual
to maintain competence.
The cost for training the 2,085 nurses [Hospital and practice nurses in primary care (PNs) and Out
of Hours Nurses (OOH)] targeted as outlined in the National Model of Care for Asthma to attend
half day workshop (assume average of 10 staff on workshop). This would require CNS to provide
209 half day workshops at an approximate cost of €26,334 i.e. CNS salary x (209 x 3 hours). The
cost for the HSE nurses (excluding the PNs) above to attend a 3 hour workshop is approximately
€124,380 and for Out of Hours nurses training €14,670. However, for primary care practice nurses
(PNs) training places are included for these nurses to attend when slots are available i.e. as part
of the 10 nurses slots (their time to attend is provided by the GP practice). Although staff costs
are quantified above, these are an opportunity cost in that staff are released from other duties
to attend/deliver trainingc.
NCHD training
This is undertaken by the consultant specialists as part of medical education (undergraduate
and post graduate). There is no implementation cost for this.
Consultants training
Updated training on their own time assisted by local Asthma Medical/Respiratory Consultant
Lead. (This is completed in non-specialist consultant own time and is not included in costs).
Consultants are funded for CME updates as part of their contract of employment. Each acute
hospital site admitting adult patients with acute asthma have an assigned designated local
lead (approx. 35). It is envisaged that the local Asthma Medical/Respiratory Consultant lead
may have to provide 3, three hourly teaching sessions per year. The hourly cost for local asthma
consultant lead is estimated at €88/hourd. Each session (including preparation time) estimated
costing €264.00.
GP training
An on-line education programme has been developed by the ICGP in conjunction with the
National Clinical Programme for Asthma.
Access is free of charge for members of the ICGP.
(This is completed in one’s own time and not included in costs).
c Salary formula as per Budget Impact Analysis of Health Technologies in Ireland was used for both grades and formula as per
Regulatory Impact Analysis used with adjustment for nursing hours.
d In line with consolidated salary scales in accordance with clause 2.31 of the Haddington Road agreement http://www.hse.ie/
eng/staff/Benefits_Services/pay/nov13.pdf
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 149
Pharmacist training
In addition a number of pharmacists and other health professionals have registered for this
programme.
This is completed in the pharmacist’s own time and not included in the costs of the programme.
Practice nurses 540 No salary costs to HSE (GP) No HSE salary cost
(primary care)
GP out of hours (GPOOH) nurses 163 As per HSE nursing above €14,670
(HSE supported) €90 x 163 = €14,670
Local Medical/Respiratory 35 sites €264 x3 x35 sites = €27,720 €27,720
Consultant Hospital Asthma Lead
may have to provide up to 3
teaching sessions per year.
Clinical Nurse Specialist (CNS) 2,085 Training session is 3hrs = €126 €26,334
Respiratory – costs as trainers (HSE, PNs, OOH (@ €42/hour)
nurses) There are 209 sessions x 3
Nurses for hours required to complete
training training of staff
€126 x 209 = €26,334
Cost of attendance at training for HSE staff = €193,104
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150 (aged 16 years and older)
Possible additional cost implications arising from implementing the guidelines recommendations
include:
A. Recommendation that a spacer device is used with a pressurized multidose inhaler (pMDI)
inhaler in mild-moderate asthma exacerbations rather than wet nebulisation for salbutamol
bronchodilation where possible.
The acute guidelines recommend that as standard practice that the reliever salbutamol, be
given for relief of bronchospasm. However, in many cases current practice is that this is given by
a nebuliser and face mask usually in an acute setting such as GPOOH or hospital ED. However,
international guidelines have recommended for some time that in cases of mild to moderate
exacerbations salbutamol should be given as a pMDI using a spacer device (either Volumatic®
or disposal once off paper spacer). The rationale for this approach is that patients will learn to
treat acute asthma symptoms using their own salbutamol inhaler at home rather than attend
needlessly to ED or GPOOH for nebulisation therapy. In addition, as part of the proposed Asthma
Watch chronic disease management (CDM) structured review patient education will focus on
managing exacerbations with a pMDI and spacer with advice as to when to attend ED and
GPOOH if this is ineffective. The pMDI and the nebuliser devices are equally effective for the
delivery of bronchodilators in the acute care setting. However, in such cases where pMDI and
spacers are used, a wet nebuliser will need to be available in GPOOH or ED in case a mild-
moderate exacerbation progresses and/or the reliever response is poor with the pMDI and
spacer and in cases where patients present with more severe exacerbation cases. (76, 77)
in the emergency department for adults (although in children this was reduced). Peak flow
and forced expiratory volume were also similar for the two delivery methods.
• The main advantage of using the pMDI with spacer approach is that it will reduce patient
over-use of nebulisers in acute situations for less severe exacerbations. Often, patients focus
on nebuliser therapy instead of standard inhaler with spacer and as these are generally
not available at home this can encourage a reliance on hospital care, and lead to repeat
hospital attendances by some patients for wet nebuliser although pMDI and spacer would
be adequate.
Possible costs
The Volumatic® spacer or paper spacer requires less storage space and at similar cost. Many
patients already use a spacer device but are unlikely to bring to an acute care setting. The cost
of the Volumatic® spacer under the community drug scheme is €3.34 (Feb 2014). The Volumatic®
pacer (single patient use) can be supplied to the patient on discharge from hospital (about 80%
of patients). The annual potential costs of this approach is as follows: GPOOH attendances =
21,800 (€72,812) and ED attendances = 12,000 (€40,080). The annual possible savings, less use of
nebulisers $8* x 27,040 (80%), converted from $ to € PPP, IRE, 2013 = 0.832.
*Dhuperet al. reported equivalent efficacy of β2 agonist delivery using a metered dose inhaler
(MDI) with a spacer device compared to using a wet nebuliser in asthma patients. However,
the median cost of treatment per patient was $10.11 (SD $10.03-$10.28) vs. $18.26 (SD $9.88-
$22.45) in the spacer and nebuliser groups, respectively (p < 0.001). They concluded that there
is no evidence of superiority of nebuliser to MDI/spacer β2 agonist delivery for emergency
management of acute asthma in this inner-city adult population. Thus the MDI/spacer may be
a more economical alternative to wet nebuliser delivery in patients other than those with severe
exacerbations.
B. Recommendations on medications e.g. inhaled steroids and oral steroids in acute asthma
exacerbations.
In ED or in-patient, patients may be given a stat dose of oral steroids (stat doses = few cents)
and on discharge and leaving hospital (ED or in-patient), may be given a prescription for a full
course of oral steroids (paid by patient or through medical card). [MIMS Ireland publication on
GMS drug therapy, shows the cost of Deltacortril EC® i.e. oral steroids at €9.90/100 tablets, the
stat doses is usually 6 tablets at €0.60 and 5 days x 6 tablets or €3.00 per course.
action plan as an integral component. In addition Blais et al. (79) reported on a case-control
study nested within a cohort of 13,563 newly treated subjects with asthma selected from the
databases of Saskatchewan Health (1977–1993). This study was undertaken to investigate the
effectiveness of a first treatment with inhaled corticosteroids in preventing admissions to hospital
for asthma. Study subjects were aged between five and 44 years at cohort entry. First time users
of inhaled corticosteroids were compared with first time users of theophylline for a maximum
of 12 months of treatment. The conclusion from the study was that the first regular treatment
with inhaled corticosteroids initiated in the year following the recognition of asthma reduced
the risk of admission to hospital for asthma by up to 80% compared with regular treatment with
theophylline. This is probably due, at least in part, to reducing the likelihood of a worsening in
the severity of asthma.
Possible costs: Undetermined (may include drug costs under GMS or DPS schemes)
As part of the guidelines the patient will attend their GP for follow up of their asthma within 2
working days. There are potential costs with GP visits and it is recommended in the NCPA Model
of Care that patients will enter the annual assessment or Asthma Check structured review which
likely will attract increased costs at primary care level which are as yet undetermined. Central
to the implementation process will be the standardisation of an asthma review. This will optimise
treatment, ensure institution of inhaled corticosteroid therapy early in asthma management
where appropriate, encourage medication adherence and address underlying problems with
asthma care and management and include:
• Inhaler technique
• Adherence to and understanding of medications
• Self-management education including personal asthma plans management of co-
morbidities and triggers including allergic rhinitis
• Smoking cessation and/or avoidance or exposure to second hand smoke.
Possible costs: Undetermined (but likely to attract increased costs for implementation of Asthma
Check annual review of patients with asthma at primary care level).
E. Recommendations on follow up in the medical specialist/nurse led OPD clinic for 1 year for
patients admitted to hospital with acute asthma following discharge.
About 20% or more of adult asthma patients may develop a repeat exacerbation requiring
ED attendances and/or early re-admission to hospital within 1 month of discharge (73,74).
| A National Clinical Guideline | Management of an Acute Asthma Attack in Adults
(aged 16 years and older) 153
Involvement and follow up in an asthma nurse / respiratory specialist clinic has been shown
to reduce re-hospitalisation rates to 0% with asthma nurse specialist input (75). If admitted to
hospital for acute asthma it is recommend that patients be followed up in a specialist medical
OPD for 1 year until stable. Occasionally patients may be followed in specialist medical OPD
indefinitely if they have more severe or difficult to control asthma.
On average there will likely be 4 clinic visits per year (2 nurse led asthma clinic and 2 regular
medical outpatient clinics, start and end of year).
Nurse specialist x 2 clinics / year (30 minutes per clinic, @ €42/hr.) and
1,460 patients @ €21/clinic (30 minutes) x 2 clinics = €61,320
Potential savings:
The national asthma programme envisages that over 3 years of implementation that we expect
a 30% reduction or more in asthma admission. The asthma nurse led clinic linked to the specialist
asthma service would, based on international evidence (75) reduce the admission by 20%
(avoidance of re-admission of patients attending this service commenced within the hospital
prior to discharge and follow up within 1 month of discharge).
Potential savings: Asthma nurse-led clinic 20% reduction in admissions over 1-3 years
= 292 patients x €4,733.2* (admission cost/pt.) = €1.38m
F. Recommendation that all patients have a peak flow meter reading on admission to GPOOH,
ED and Hospital for ongoing assessment and management of acute asthma.
Since this usually forms part of standard medical equipment in hospital, this has not been
included.
Table 8 Estimated costs and possible savings with Implementation of Acute Asthma Attack in Adults
Guideline
Annual Estimated Cost for 1,460 acute asthma adult admissions x [€4733.2 per €6.9m
patient = cost in COAX study (20)]
Costs
Initial Set-up Costs
The HSE cost for Asthma Society of Ireland SLA cost €29,084 per year from July €116,336
2011 – June 2015 (Total)
Cost of attendance at training HSE staff €193,104
Annual ongoing costs
Possible costs spacer and pMDI €112,892
Stat doses – steroids €0.60 x 33,800 patients (ED and GPOOH) €20,280
Steroid inhaler therapy with short acting reliever inhaler Costs: Undetermined
Follow visits with GP after ED discharge Costs: Undetermined
Costs of specialist / nurse led asthma OPD visits for patients discharged after €440,920
acute asthma admissions
Peak flow meters at GPOOH and ED No extra costs
envisaged with this
A systematic literature search was performed in October 2013 and in May 2014. The search
strategy used the following PICOS.
Outcome: Most cost effective interventions for managing acute exacerbations of asthma in
adult patients > 16 years.
Children under the age of 16 were not excluded in the search terms for this work as a number of
studies that mainly concentrated on adult asthma also contained some coverage of childhood
asthma therefore to have specifically excluded any references to childhood asthma as a search
term may also have excluded some potentially useful references to acute adult asthma.
Note: The search example included was from the PubMed database. The same search strategy
was also employed on the other noted databases.
Databases Searched
The following databases were utilised in the literature search
• PubMed
• Embase
• Cochrane
• Web of Science
• NHS Evidence
• Google Scholar
• Up To Date
• Clinical Key
• One Search
• Database of Abstracts of Reviews and Effects (DARE)
• NHS Economic Evaluation Database
• Health Technology Assessment Database
| Management of an Acute Asthma Attack in Adults | A National Clinical Guideline
156 (aged 16 years and older)
Figure 2 below is a Flow Diagram of retrieved studies which is a short flow diagram detailing the
numbers of articles retrieved and progress through the economic search.
Full-text articles
Full-text articles
assessed for eligibility
excluded,
(346+8)
(300)
(n =354)
Studies included in
qualitative synthesis
(n =54)
22 Department of Health UK, An Outcomes Strategy for COPD and asthma: NHS Companion
Document, 2012, p.9 www.gov.uk/government/uploads/system/uploads/attachment_
data/file/216531/dh_134001.pdf
23 The NHS Information Centre, Health Survey for England 2010, Summary of Key Findings
www.hscic.gov.uk/catalogue/PUB03023/heal-surv-eng-2010-resp-heal-summ-rep.pdf
24 Haahtela T, et al. A 10 year asthma programme in Finland: major change for the better.
Thorax 2006;61:663-670
25 National Clinical Programme for Asthma, HSE, Asthma Check, Chronic Disease Watch –
Asthma, 2012 www.hse.ie/eng/about/Who/clinical/natclinprog/asthma/workstreams/
asthmacheck.pdf
26 National Clinical Programme for Asthma, HSE, Emergency Paediatric Asthma Guideline,
2013 www.hse.ie/eng/about/Who/clinical/natclinprog/asthma/workstreams/paed%20
guideline.pdf
27 Stallberg B, et al. A real-life cost-effectiveness evaluation of budesonide/formoterol.
Respiratory Medicine, 2008. Oct;102(10):1360-70.
28 Louis R, et al, A comparison of budesonide/formoterol maintenance. International Journal
of Clinical Practice, 2009; Int J Clin Pract, 63(10), 1479-88.
29 Price D, et al. A pragmatic single-blind randomised controlled trial and economic
evaluation of the use of leukotriene receptor antagonists in primary care at steps 2 and
3 of the national asthma guidelines (ELEVATE study). Health Technol Assess, 2011; 15 (21),
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30 Colice G, et al, Asthma outcomes and costs of therapy with extrafine beclomethasone
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31 Miller E et al . Budesonide/formoterol as maintenance and reliever treatment. Canadian
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32 Lewis et al, Clinical And Economic Burden Of Asthma And Chronic Obstructive Pulmonary
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Acting Beta Agonist Fixed-Dose Combinations. Value in Health, May 2014; Volume 17, Issue
3, Pages A174,
33 Wilson E, et al, Cost effectiveness of leukotriene receptor antagonists versus inhaled
corticosteroids for initial asthma controller therapy: a pragmatic trial. Pharmacoeconomics,
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34 Willson J, et al, Cost effectiveness of Tiotropium in patients with Asthma. Applied Health
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35 Tamminen K, et al. Cost-effectiveness analysis of budesonide/formoterol maintenance and
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36 Kemp L, et al, Cost-effectiveness analysis of corticosteroid inhaler devices in primary care
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37 Morishima T, et al. Cost-Effectiveness Analysis of Omalizumab for the Treatment of Severe
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38 Gerzeli S et al, Cost-effectiveness and cost-utility of beclomethasone/formoterol versus
fluticasone propionate/salmeterol in patients with moderate to severe asthma. Clin Drug
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39 Wickstrom J, et al. Cost-effectiveness of budesonide/formoterol for maintenance and
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40 Bruggenjurgen B, et al. Economic evaluation of BDP/formoterol fixed vs two single inhalers
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41 Hiangkiat Tan. Impact of Asthma Controller Medications on Clinical, Economic, and
Patient-Reported Outcomes. Mayo Clin Proc. 2009, 84(8), 675-684.
42 Canadian Agency for Drugs and Technologies in Health (CADTH). Long-acting beta(2)-
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67 Gonnah R, Hegazi MO, Hmdy I, Shenoda MM. Can a change in policy reduce emergency
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68 Bahadori, K at al, Economic burden of asthma: a systematic review. BMC Pulmonary
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69 SadatsafaviM, at al. Costs and health outcomes associated with primary vs secondary
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70 Steuten L et al. Cost-utility of a disease management program for patients with asthma. Int
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71 Mogasale and T Vos. Cost-effectiveness of asthma clinic approach in the management of
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